Rural Health Quarterly 2.3 – Summer 2018

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Summer 2018

Rural Health Quarterly

FALLOUT Rural Americans ran the arms race, but their true sacrifice is only now coming into focus. pp. 20-23

A Publication of the F. Marie Hall Institute for Rural and Community Health









Infection Prevention

Patient Consultation

Antimicrobial Stewardship

is Leading the Way in Providing Hospitals with Comprehensive

Antimicrobial Stewardship Programs All Acute Care Hospitals, Skilled Nursing Facilities and Long-Term Care Facilities must have antimicrobial Stewardship Programs as Mandated by CMS, Joint Commission, State and Federal Regulations. TeleMed2U delivers... A comprehensive Antimicrobial Stewardship Program Improved physician prescribing - right drug, right dose, right duration Decreased pharmaceutical anti-infective costs Reduced resisitance rates on hospital antibiograms Successful Telemedicine based integration of infection prevention and patient consultations Pioneered telemedicine-based program to be recognized nationally by: Agency for Healthcare Research and Quality (AHRQ) Infectious Disease Society of America (IDSA) California Department of Public Health 916-740-3721 TeleMed2U is a 100% telemedicine-based multi-specialty group of board-certified physicians who provide medical consultations for patients and primary care providers.


SUMMER 2018 What Works? A Peek into Vermont’s Model of Maternity Care 15

20 Years of Telemedicine Regulation Many regulations that made sense in a face-to-face world have hampered the successful delivery of telemedicine.


Amid Shortage, AHEC Scholars Program Works to Recruit Rural Health Workers Area Health Education Centers across the country are implementing a new strategy beginning September 2018.


Cover Story // Rural Fallout: Workers Exposed to Radiation During Arms Race Seek Compensation 20

Consequences of the Research Funding Shell Over the past decade, U.S. biological and medical research has fallen off due to budget cuts, sequestration and inflationary losses. Countless initiatives important for the health of rural Americans will suffer if there isn’t enough money to go around.

Tuition-Free Med School Touches Off Multimillion-Dollar Debate 27

Webside Manner: More Medical Schools Embrace Telemedicine Training 30




THE CMS Rural Health Strategy The Centers for Medicare & Medicaid Services has launched the agency’s first Rural Health Strategy to help improve access to high quality, affordable health care in rural communities.

There's An Illegal Market For An Opioid Addiction Medication. Is That Such A Bad Thing?



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Volume 2, No. 3 Summer 2018

Publisher Billy U. Philips, Jr., Ph.D., executive vice president and director of the F. Marie Hall Institute for Rural and Community Health, Lubbock, TX Editor in Chief Scott G. Phillips



Section Editors Debra Flores—Health Education Travis Hanson—Health Technology Catherine Hudson—Rural Research Ronald N. Martin—Behavioral Health Cameron Onks—Public Policy Copy Editors Melanie Clevenger Traci Butler Carroll


// PUBLIC POLICY 13 - 23

Research Associate Debra Curti Web Developer Miguel Carrasco

// HEALTH Technology 34


Contributors O.M. Campbell Traci Butler Carroll Kristine Crane Jake Harper Barbara Mantel Julie Rovner Dava Stewart Contacts and Permissions Email RHQ at For more contact information, visit

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Rural Health Quarterly is a free publication of the F. Marie Hall Institute for Rural and Community Health at the Texas Tech University Health Sciences Center.

SuMMER 2018 | RHQ   3

RHQ Rural Health Quarterly

84 million Americans

Maybe even you,

have prediabetes. person-ABOUT-TOFACT-CHECK-THIS-FACT.

Rural Health Quarterly (ISSN 2475-5044) is published by the F. Marie Hall Institute for Rural and Community Health, 5307 West Loop 289, Lubbock, TX 79414, and the Texas Tech University Health Sciences Center. Copyright 2018—Texas Tech University Health Sciences Center. The articles published in Rural Health Quarterly do not necessarily reflect the official policies of the F. Marie Hall Institute or of the Texas Tech University Health Sciences Center. Publication of an advertisement is not to be considered endorsement or approval of the product or service. Rural Health Quarterly is published four times a year and distributed without charge upon request to individuals residing in the U.S. meeting subscription criteria as set forth by the publisher. RHQ ADVISORY BOARD Ogechika Alozie, associate professor/chief medical informatics officer, TTUHSC El Paso Paul Fowler, associate dean for the School of Medicine Administration, TTUHSC Permian Basin Coleman Johnson, special assistant to the President, TTUHSC Retta Knox, RN, Hart School-Based Health Clinic, Hart, TX Susan McBride, Ph.D., RN, School of Nursing, TTUHSC Linda McMurray, executive director at TTUHSC Larry Combest Community Health and Wellness Center Will Rodriguez, senior managing director for CMHC, TTUHSC Ken Stewart, Ph.D., director of Community Development Initiatives, ASU, San Angelo, TX Dr. Julie St. John, assistant professor, TTUHSC Abilene Shari Wyatt, rural health specialist, State Office of Rural Health, Texas Department of Agriculture

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Primary care nurse practitioners will train to work in rural and underserved areas of Alabama under a new program in the University of Alabama’s Capstone College of Nursing. BAMA-Care calls for at least 50 percent of participants to be from underrepresented minority groups and/or disadvantaged backgrounds.

The University of Arizona Health Sciences has been awarded two grants to help improve health care access for rural communities. The AHEC and Advanced Nursing Education Workforce grants will total $2.5 million over five years and $1.4 million over two years, respectively. | 08.18.18 | 07.19.18





Federal Communications Commission increased Alaska's Rural Health Care program budget and approved funding of Alaska Communications’ contracts. The program’s previous $400 million cap was set in 1997 and was never indexed for inflation. The increase represents what the funding level would be today had the initial cap included an inflation adjustment.

In June, Arkansas began rolling out Medicaid work requirements. This change in eligibility requires regular online reporting of hours worked, despite the fact that the state ranks 48th in the country for internet access and 44th for poverty. After the first month, about 7,000 people failed to report their working hours.

A study in the journal Health Affairs said California’s success in reducing maternal mortality—seven pregnancy-related deaths for every 100,000 live births, compared to a U.S. average of 22 per 100,000— came thanks to a four-pronged plan of attack that combined analyzing public health data, convening public and private health groups, creating a data system to measure progress and developing health interventions for use across the state. | 07.18.18 | 08.21.18 | 09.04.18

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Mpower, an organization that works towards bettering the lives of mental health patients, has launched a clinic in Mumbai to combat mental health that is easily accessible for all.

NewFOUNDLAND & Labrador Memorial University of Newfoundland is combining genetic science and rural health care delivery, thanks to a $3.8 million federal funding grant.

The Centre For Rural Sexual Health has warned Australians ‘Don’t Go Viral’ for its latest campaign. The ‘Don’t Go Viral’ campaign targets young Australians and aims to encourage them to get tested for sexually transmitted infections.

Organizers say getting people in cities to open up about their mental health issues is harder than it is with people from the metros. And penetrating into rural India – the villages where such a large percentage of the population lives – is even more challenging.

$2.4 million will go toward a partnership between MUN and NL Centre for Health Information. The two entities plan to create a customized genetic database from residents living in the province through the use of a Genetic Code sequencing machine—the first of its kind in Newfoundland and Labrador. | 09.11.18 | 09.11.18 | 09.10.18

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What’s news in your neck of the woods? Let us know: Email: Email your rural health news to RHQ at

U.S. Mail: Rural Health Quarterly, F. Marie Hall Institute for Rural & Community Health, 5307 West Loop 289, St. 301 Lubbock, Texas 79414

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Web: Find more RHQ contacts at or follow us on Facebook at

Delaware //


A Delaware woman who lived by herself in a rural setting was exposed to rabies in July and died from it in August. The last known person to die of rabies in Delaware was a 4-yearold boy in 1941. The same week the woman was exposed, the state restored funding to the Office of Animal Welfare for its rabies program, after lawmakers cut it out for a year.

ECHO Hawaii has launched a free webinar that schools doctors on topics ranging from the side effects of antidepressants to the art of weaning a patient off pain medication. ECHO Hawaii is sponsored in part by the Hawaii State Rural Health Association. | 08.29.18

FLORIDA // Tallahassee Memorial Hospital saves upwards of $1 million per year in cost avoidance through its telehealth platform, despite not being able to bill for a vast majority of the telemedicine services it provides. The program has been successful in lowering readmission rates.| 08.31.18

GEORGIA // Georgia’s Legislature is once again brainstorming legislation to address the state’s rural health care crisis. Sixty-four of 159 counties have no pediatrician; 79 have no obstetrician/ gynecologist; and nine simply have no doctor. Health outcomes for Georgia patients lag accordingly, with the state ranked among the worst 10 states for most measures. | 07.16.18


Georgia’s legislature decided not to expand Medicaid under the Affordable Care Act, saying the state could not afford the long-term cost.

St. Luke's Health System is investing $3.4 million in a virtual care center, a "high tech hub" with a medical team available to provide assistance 24/7. The center will be able to connect doctors with rural Idahoans and those with mobility issues. When the new center opens, specialists in Boise will use the remote monitoring equipment to both diagnose and treat patients. | 08.17.18 | 08.29.18


United Kingdom


Malawi Half the health care facilities in Malawi lack clean water and sanitation, and electricity blackouts mean equipment used during labour may not be sterilised properly. Hospitals frequently run out of essential supplies such as chlorine, soap and antiseptic gloves. Women are also asked to bring certain items to the hospital before giving birth: a plastic sheet called a macintosh, a razor blade to cut the cord and a plastic tub to bathe the baby.

In rural agricultural communities in Peru, kidney failure is on the rise. Doctors and scientists suspect that dehydration and heat stress—probably in combination with other factors, such as heavy metal pollution and pesticide exposure—could be behind it.

Rural communities in the UK ‘could die out by 2050’ unless the health care system for the elderly improves, experts warn. In 2017, there were 1.35 million people aged 85 and over in England. By 2031, it could exceed two million. | 09.07.18 | 08.14.18 | 09.11.18 SUMMER SPRING 2018 | RHQ   7

Rural Reports //



A new Illinois law to increase access to mental health professionals among people on Medicaid was passed this summer. Senate Bill 3049 requires Medicaid to provide reimbursements for behavioral health telehealth services. Many hospital systems in Illinois offer some form of telehealth.

A $1 million earmark in the Massachusetts state budget is aimed at creating a pipeline of primary care physicians to areas of western Massachusetts where there is a severe shortage of doctors. Clinical training for the students takes place in underserved areas. | 08.24.18

INDIANA // South Ripley Schools partnered with Margaret Mary Health and the Indiana Rural Health Association to establish a new School-based Telehealth Clinic, which connects patients to remote doctors with the help of an on-site school nurse. Parents can also connect to their child’s medical visit without leaving work. | 08.02.18

IOWA // At the University of Iowa in Iowa City, the College of Pharmacy is operating a telehealth clinical pharmacist service called Centralized Healthcare Solutions. CHS is under the umbrella of the College of Pharmacy and any revenue generated flows to the university.

KENTUCKY // The Kentucky State Loan Repayment Program (KSLRP) is now accepting applications for 2018-2019. The KSLRP is a loan repayment assistance program that helps to recruit and retain health care providers in rural and underserved communities across the state. Applicants selected to participate in the competitive program agree to work full time for two years providing primary care services in a Health Professional Shortage Area. | 09.06.18| 06.25.18

MICHIGAN // A pathology professor and five second-year medical students have created the Healthy Aging Initiative, a program where Central Michigan University medical students provide free health screenings for geriatric patients who live in rural areas of Central Michigan. The project started in January 2018. | 09.07.18

LOUISIANA // In just two years, the infant mortality rate in Central Louisiana's povertystricken and rural Region 6 was halved, down to 4.7 deaths per 1,000 live births in 2015, the lowest of the state’s nine public health regions. Their solution was straightforward: Offer more care. | 09.01.18


The Kansas Legislature passed a measure requiring health insurers to provide the same level of coverage for telemedicine services as in-person visits.

A Colorado startup, Numbers4Health, is receiving grant funding from Microsoft to expand its school-based telehealth platform to bring connected health services to underserved communities in Maine, as well as in California and Texas.

In the U.S., more than 43 million family members or friends provide unpaid care to an ailing adult or child. A new University of Minnesota School of Public Health study shows the situation could be particularly difficult for informal caregivers in rural areas, who often lack the workplace flexibility and support they need to juggle their many responsibilities. | 06.03.18| 08.02.18 | 08.14.18 | 08.15.18


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MISSISSIPPI // In Mississippi, more than 62 percent of youth who suffer a major depressive episode — 13,000 kids — don’t get any professional help, according to national statistics from a recent report. The state’s Department of Mental Health has cut hundreds of staff members, reduced some services, and closed programs, including one that provided communitybased mental health services to at-risk youth. About 44 percent of the state’s children live in rural communities. | 06.25.18

MISSOURI // A $90 million billing scheme blasted in a state audit of a rural Missouri hospital spread to as many as 10 other hospitals, a couple who are shareholders in the company has alleged in federal court. The complaint alleges that HMC Hospitals misappropriated $2 million from the 10 small hospitals, pushed four of the hospitals into default on $29.3 million in loans and submitted false hospital reports to Medicare and Medicaid. | 08.13.18



The American Stroke Association has announced a $6.5 million statewide commitment over three years to enhance Nebraska’s system for responding to and caring for people with strokes. A law establishing the stroke system took effect in 2017, although an advisory council had begun working on it about a decade ago.

A group representing about 90 New York hospitals and nursing homes has reached a tentative three-year agreement with the state's largest health care workers union. About 70,000 workers, including nurses, nursing assistants, lab technicians and other professional staff, will receive annual wage increases of 3 percent over the life of the contract, according to a union news release. | 08.22.18 | 07.17.18

NEVADA // 8,000 Nevadans in 14 counties who faced the loss of their coverage after Anthem Blue Cross Blue Shield pulled out of the state's health care exchange have been thrown a lifeline. A deal with Centene Corp. in partnership with the Nevada-based Hometown Health will help ensure coverage | 08.15.18

Lumberton, N.C.-based Southeastern Regional Medical Center, a 452-bed hospital in a rural county, is looking to its Walmart urgent care clinic to avoid straining emergency departments with nonemergency care. The Walmart clinic only has one exam room, and service prices are posted on the wall. | 09.10.18



Montana's first psychiatry residency program will launch at Billings Clinic, bringing trained psychiatric professionals to rural Eastern Montana. Montana has the highest suicide rate in the nation.

Two New Mexico health plans are launching a telehealth service for some 40,000 members that will allow them to call a number posted on the back of their insurance cards, be screened by a nurse and, if approved, connect with a doctor for a diagnosis and treatment. The goal is to reduce unnecessary traffic in ERs and doctors’ offices. | 09.06.18 | 06.15.18



U.S. Senator Heidi Heitkamp, a founding member of the Senate Broadband Caucus, announced over $7.2 million in federal funding for North Dakota that will support rural high-speed internet infrastructure improvements, especially in rural and tribal areas. | 08.31.18

OKLAHOMA // The Health and Wellness Center of Sallisaw has received a $15,000 grant from the Carolyn Watson Rural Oklahoma Community Foundation to increase services to rural Oklahoma. | 08.24.18 SUMMER 2018 | RHQ   9

Rural Reports //



Bend, Ore.-based St. Charles Health System is mulling the idea of becoming a teaching hospital to draw in more physicians amid recruitment struggles. However, the majority of medical residencies are funded by Medicare, which places caps on the number of residents hospitals can have. St. Charles Health System's program is capped at one resident per year.

Ambulance departments in rural areas of Vermont face growing costs and increasing demands of time and training, and some volunteer-run departments have been forced to close, including two departments in the Northeast Kingdom in the last year, when those demands become too much to manage. Staffing, training, costs and other challenges face the state's roughly 80 ambulance departments. | 08.27.18

SOUTH CAROLINA // A multimillion-dollar pool of state money set aside to help struggling hospitals is about to run out, but South Carolina’s Medicaid agency’s director says he still wants to find ways to improve health care access in the state’s rural areas. A new policy will allow the S.C. Department of Health and Human Services to help pay for up to 25 percent of the capital costs associated with mergers between rural hospitals. | 08.25.18

SOUTH DAKOTA // After a string of alarming incidents, regulators are threatening to withdraw critical funding from a a hospital on the Rosebud Sioux reservation in South Dakota. The proposed sanctions are the latest blow for U.S. Indian Health Service, which has faced criticism from regulators, members of Congress and tribal leaders over the poor performance of its network of hospitals and clinics, particularly those in a swath of the rural Midwest. | 08.17.18

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TENNESSEE // Stan Brock, founder of the Knoxvillebased Remote Area Medical (RAM) organization, died on August 29 in Rockford, Tennessee at the age of 82. RAM clinics provide free health care services to people who live in rural areas where such services are not available or are inaccessible. During Brock’s 33-year tenure, RAM provided 740,000 people with more than $120 million of free health care. | 09.05.18 | 09.04.18

VIRGINIA // The James Madison University School of Nursing has begun a project it hopes will help increase the number of nurses serving rural communities.The school is training nursing students in the Undergraduate Primary Care and Rural Education Project (UPCARE). | 08.30.18

TEXAS // The Texas Higher Education Coordinating Board has approved Sam Houston State University’s doctorate in osteopathic medicine. The program will collaborate with hospitals in rural East Texas counties to establish residency-training programs.| 08.14.18

UTAH // The Utah Legislature passed a bill to boost funding for health care in the state, including $120 million to address the opioid epidemic's impact in rural areas through support for rural health centers. The bill also increases funding for medical research and efforts to reduce maternal mortality. | 08.24.18

WEST VIRGINIA // A West Virginia University partnership with three divisions of the state health department has developed the Appalachian Rural Health Integration Model and a program which will target the prevalence of neonatal abstinence syndrome and the effect it has on children's development. | 09.11.18

WYOMING // Davenport University and the Wyoming VA Health Care Center are partnering on a nursing initiative to enhance health care delivery for rural veterans. | 08.14.18


Rural Research //

Consequences of the Research Funding Shell Game


eople living in rural communities have unique health and health care challenges. They are more likely to have limited access to affordable and quality care, they experience health inequities and high rates of chronic disease, and they are confronted with the lack of mental health services and shortages of health care providers. The fact that 19 percent of the U.S. population lives in rural areas Catherine Hudson and face these obstacles more often than those in urban DIRECTOR FOR RURAL areas reinforces the need for more research and innovation HEALTH RESEARCH to improve health outcomes in these communities. F. Marie Hall Institute for Biomedical research is a field of science that examines Rural and Community diseases and looks for ways to prevent and treat them. It can Health provide important information about disease trends and risk factors, develop treatments or interventions, and examine health care costs and use. Generally, funds for medical research come from governmental or public sources. The National Institutes of Health (NIH) is the largest public funder of biomedical research in the world, investing more than $32 billion a year to enhance life and reduce illness and disability. NIH-funded research builds the research foundation that drives discovery and has led to breakthroughs and new treatments that help people live longer, healthier lives. Stability of research dollars is dependent on the economy. Over the past decade, U.S. biological and medical research has fallen off due to budget cuts, sequestration, and inflationary losses. The NIH experienced a loss of 22 percent of its capacity to fund research from 2003 to 2015. This reduction in funding has resulted in fewer grants which leads in turn to fewer new discoveries and, ultimately, in talented researchers leaving the field. Medical research dollars are also subject to political maneuverings. It was recently disclosed that funding designated for rural health programs, medical research and other priorities was shifted to cover expenses that resulted from President Trump’s zero-tolerance illegal immigration policy. According to Politico, at least $40 million in HHS funds have been spent on care, housing and reunification efforts for families separated at the border. President Trump’s budget proposals for 2017 and 2018 both included further cuts to NIH funding, but these suggested cuts have been largely ignored by Congress. The NIH budget grew by roughly $2 billion in 2018 and is poised for another increase in 2019. Although efforts of US science agencies including the NIH have been historically supported by lawmakers, scientist shouldn’t become complacent. It is only a matter of time before those funding reductions become reality, leaving researchers in a lurch. One might say that private sources of funding for research is an option, but the generosity of private philanthropists such as Bill Gates and Mark Zuckerberg account for only a small percentage of the funding needed for cutting edge research endeavors. Private investment is another source of revenue, of course, but many private investors are looking for a short term return on their investments, an approach which is not always conducive to scientific discovery. Inequity in the distribution of government funding is a fact of life, but there are countless initiatives important for the health of rural Americans that will suffer if there isn’t enough money to go around.


Grant WATCH // EXTRAMURAL LOAN REPAYMENT PROGRAM FOR HEALTH DISPARITIES RESEARCH (LRPHDR) The objective of the LRP-HDR is to recruit and retain highly qualified health professionals into research careers that focus on minority health disparities or other health disparities. The Program serves as an avenue for NIH and the National Institute on Minority Health and Health Disparities (NIMHD) to engage and promote the development of research and research programs that reflect the variety of issues and problems associated with disparities in health status. This requirement highlights the need for the involvement of a cadre of culturally competent health professionals in minority health disparities and other health disparities research. The NIH invites qualified health professionals who contractually agree to engage in NIH mission-relevant research for an average of at least 20 hours each week for at least two years, initially, to apply for an award in the Extramural LRPs. The Extramural LRPs repay up to $35,000 annually of a researcher's qualified educational debt in return for a commitment to engage in NIH mission-relevant research at a domestic, nonprofit, or government entity. Research funding from NIH is not required to participate in the Extramural LRPs. LRP awards are based on an applicant's potential to build and sustain a research career. Extramural LRP applications are accepted annually from September 1 through November 15, 8:00 p.m. EST. All LRP applications must be submitted electronically using the NIH LRP Website, SPRING 2018 | RHQ   11

RHIhub Your First STOP for

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INFORMATION Online Library RHIhub’s online library includes over 12,000 resources, updated daily. Find publications, research, organizations, maps, and websites. Search news and events to stay current on rural health issues. Looking for funding? Search for the latest federal, state, and foundation opportunities:

Topic & State Guides Compiles in-depth information on rural health topics and your state. Includes key resources, funding, maps, events, news, statistics, and more.

Rural Community Health Gateway Find tools and proven methods to help build effective community health programs and improve services. • Evidence-Based Toolkits – Step-by-step guides to develop programs that improve the health of rural communities, based on evidence-based and promising interventions. • Rural Health Models and Innovations – Find examples of rural health projects other communities have undertaken. Gain insights from their experiences to help you develop new programs in your area.

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Tools for Success Access resources that support grantwriting, demonstrate program impact, and plan for the sustainability of your program. • Am I Rural? – Determine if your program is considered rural based on various definitions of rural • Economic Impact Analysis – Estimate the impact of your program on your community’s economy


The CMS Rural Health Strategy The following information on the CMS Rural Health Strategy was provided by the Centers for Medicare & Medicaid Services. Learn more about the program at http://


he Centers for Medicare & Medicaid Services (CMS) has launched the agency’s first Rural Health Strategy to help improve access to high quality, affordable health care in rural communities. The strategy is intended to provide a proactive and strategic focus on health care issues across rural America to ensure the nearly one in five individuals who live in these areas have access to care that meets their needs. CMS is organizing and focusing its efforts to apply a rural lens to the vision and work of the agency. The CMS Rural Health Strategy supports CMS’ goal of

putting patients first. Through its implementation and continued stakeholder engagement, this initiative will enhance the positive impacts CMS policies have on beneficiaries who live in rural, underserved areas. This Administration understands that one of the keys to ensuring that those who call rural America home are able to achieve their highest level of health is to advance policies and programs that address their unique healthcare needs. BACKGROUND Approximately 60 million people live in rural areas across the United States – including millions of Medicare and Medicaid beneficiaries. CMS recognizes the many obstacles that rural Americans face when accessing health care services, including a fragmented health care delivery system, stretched and diminishing rural health workforce, unaffordability of insurance, and lack of access to specialty services and providers. CMS developed this strategy to focus

on areas where the agency can better serve individuals in rural areas and work to avoid unintended consequences of policy and program implementation for these communities. SUMMARY The new strategy builds on several overarching CMS priorities launched by the Trump Administration, including reducing regulatory burdens and empowering patients and providers to make more informed decisions about their health care. In addition, the CMS Rural Health Strategy underscores CMS’ commitment to combat our nation’s opioid epidemic given its disproportionate impact on rural communities. The CMS Rural Health Council —an agency-wide panel of experts formed in 2016—developed the CMS Rural Health Strategy with input from 14 listening sessions with rural health care providers, consumers, and other stakeholders. The Council gathered real world evidence on the challenges and local solutions associated with providing

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high quality health care in rural communities to inform the development of a strategic plan to improve healthcare in rural America. Representing an agency-wide mindset, the strategy aligns with the goals of the Health Resources and Services Administration’s (HRSA) Federal Office of Rural Health Policy (FORHP), which was created in 1987 to advise the Secretary of the U.S. Department of Health and Human Services on health care issues impacting rural communities, including: • • •

Access to quality health care and health professionals; Viability of rural hospitals; and Effect of the Department’s proposed rules and regulations, including policies under Medicare and Medicaid, on access to and financing of health care in rural areas.

The CMS Rural Health Strategy identifies five specific objectives intended to achieve the agency’s vision for equitable rural health: 1. Apply a Rural Lens to CMS Programs and Policies CMS recognizes the need to look at policymaking, program design, and strategic planning through a specific lens to promote health equity among all populations that it serves. The first objective focuses on areas where the agency can better meet the needs of rural populations and avoid unintended consequences of policy and program implementation for these communities. To accomplish this, CMS will: •

Apply a newly-developed checklist to relevant policies, procedures, and initiatives that impact rural communities; and Identify and accelerate evidence-based practices to improve access to services and providers in rural communities.

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2. Improve Access to Care Through Provider Engagement and Support The second strategic objective is to improve access to care through provider engagement and support. This objective focuses on: • •

Maximizing scope of practice; Providing technical assistance to health care providers to ensure that they can fully participate in CMS programs; and Identifying new ways to overcome patient barriers to access, such as a lack of transportation.

5. Leverage Partnerships to Achieve the Goals of the CMS Rural Health Strategy A key objective of the strategy is to leverage partnerships with stakeholders nationally, as well as at the regional, state, and local levels. To accomplish this, CMS will: •

3. Advance Telehealth and Telemedicine The third objective focuses on the advancement of telehealth and telemedicine. Telehealth has been proven to be a successful tool to improve access to care and help meet the needs of rural areas that lack sufficient health care services. To help promote the use of telehealth, CMS will seek to reduce barriers stakeholders identified such as reimbursement, cross-state licensure issues, and the administrative and financial burden to implement telemedicine.

4. Empower Patients in Rural Communities to Make Decisions About Their Health Care CMS will leverage existing rural communication networks to empower patients with the information and tools to engage in their health care and will explore ways to support enhanced access through the use of health information technology (health IT). CMS will work to ensure information is reaching rural beneficiaries by: •

Collaborating with rural communication networks to develop and disseminate easy-to-understand materials; Supporting the adoption of health IT and the development of infrastructure to enhance patient

access to health information; and Fostering engagement of rural beneficiaries in their health care.

Explore opportunities with the Office of the National Coordinator for Health Information Technology and other federal partners to promote interoperability of health information and increase the use of electronic health records among individuals and their health care providers and care teams. Work with federal and state partners to understand and evaluate the impacts of CMS programs on rural communities, and develop recommendations. Meet with health plan representatives to discuss challenges and strategies to increase participation in rural areas. Work with the Centers for Disease Control and Prevention to increase the focus on maternal health, behavioral health, substance abuse, and the integration of behavioral health and primary care. Work with state Medicaid agencies and other state partners to advance rural health strategies for Medicaid eligible individuals, including people with disabilities, dual-eligible beneficiaries, and people with substance use disorders.

CMS will continue to collaborate with agency partners across the U.S. Department of Health and Human Services (HHS), including Health Resources and Services Administration’s (HRSA) Federal Office of Rural Health Policy, to implement this strategy.



What Works? A Peek into Vermont’s Model of Maternity Care BY O.M. CAMPBELL


n a recent United Health Foundation report, Vermont was named the third healthiest state overall in the country. Since the creation of the report in 1990, Vermont has risen 17 places. It enjoys a low percentage of uninsured people (3.8 percent) and was ranked second in women and children’s health. Vermont’s women are especially healthy. At 61 percent, they self-reported the highest rate of “high health status” in the U.S. Babies are doing well here, too. Vermont boasts some of the lowest infant mortality and childhood poverty rates in the nation. It is consistently ranked by Wallethub as one of the best states in the U.S. to have a baby. In fact, 2017 was the second year in a row Vermont

earned the number one slot. It made the top five on measures of most midwives, OB/GYNs, pediatricians, family doctors, and child care centers per capita. One of the big hurdles to providing high-quality in rural areas is lack of health care professionals interested in working there. So how does a predominantly rural state like Vermont attract such an amazing density of health care workers? “Vermont is a wonderful place to practice medicine. The medical community … is very collegial, so it’s an inviting place to work,” said Dr. Anna Benvenuto, medical director of specialty services in the women’s health department at the University of Vermont’s Porter Medical Center in Middlebury. “The ability to create longterm relationships with families across generations is a unique and enriching experience.” What’s more, she says the “availability of a multitude of outdoor activities, vibrant arts scene, and ability to be

socially engaged offers a wide range of opportunities outside of work. There is an ability to create a manageable worklife balance.” So is there anything we can glean from Vermont’s maternity care-delivery model that might help other rural states? Benvenuto says there are a few things that really elevate the state’s care. First is the Northern New England Perinatal Quality Improvement Network, a collaborative of hospitals and homebirth midwives throughout Vermont and New Hampshire that creates protocols for pregnancy and delivery care, holds educational conferences for care providers three times a year, and performs case reviews. Currently, 25 states have active perinatal quality collaboratives, with many others in the works. States with PQCs have seen significant improvements in the care of mothers and newborns. PQCs goals include reducing newborn infections, neonatal abstinence syndrome, elective early deliveries, maternal hemorrhage and hypertension,

Despite being one of the most rural states in the country, Vermont continues to be one of the nation's healthiest states. In RHQ's 2017 Rural Health Report Card, Vermont earned an A+ and ranked second in the nation for overall rural health.

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and increasing human milk use. Next is the Vermont Child Health Improvement Program, another research and quality improvement program, which collects statistics for every Vermont hospital that provides obstetric services. They then present a summary of their report and provide an educational session for the medical staff focused on specific areas to target for improvement. Many rural states across the country are losing maternity care options. Nine percent of rural counties lost hospital obstetric services between 2004 and 2014. When hospitals struggle financially, obstetric units tend to be first on the chopping block because they are incredibly costly. Vermont has fared better than many other rural states in this respect. All of the state’s hospitals continue to offer obstetrical services, so there are no large gaps in geographic coverage like the ones appearing in other counties across the nation. “We are fortunate that hospitals continue to support birthing units. Women in many other rural areas are experiencing the closing of the nearest birthing unit—forcing long drives and reducing access to both routine prenatal care, delivery services and emergency management,” said Benvenuto. This increased access means a large proportion of women don’t miss out on critical prenatal care. Data from 2015 show 84 percent of pregnant Vermont residents received prenatal care in the first trimester and only 6.6 percent of babies were born at a low birth weight. Nationally, one of the Healthy People 2020 goals is to increase the proportion of pregnant women who receive care in the first trimester from 71 percent in 2007 to 78 percent in 2020. Lack of adequate prenatal care is associated with an increased risk of low birth weight, prematurity, stillbirth and infant death. A density of caregivers also gives patients a lot of choice, and better pre-pregnancy and intra-pregnancy health care. In most areas of Vermont, women have a choice of whether they want to see an obstetrician, midwife, or obstetric-certified family practice phy-

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sician for their maternity care. Women in other states may miss out on such care because they can’t afford it or have to travel too far to receive it. Some states allow women to access Medicaid coverage at higher incomes after they become pregnant, but adequate care before and between pregnancies can also contribute to better maternity outcomes for moms and babies.

“67 percent of the state’s rural hospitals employ a nurse midwife—that’s practically unheard of in the U.S.” “Primary care has been cultivated for decades in Vermont. This robust network means that a higher percentage of women start pregnancy with chronic medical conditions under better management,” said Benvenuto. “Many women have also pursued prepregnancy consultation, so they have a better understanding about their risks going into pregnancy. Some women choose to delay childbearing until their conditions are better controlled, reducing their pregnancy-related risks.” Vermont also has the seventh lowest caesarean section rate in the country. C-sections involve many of the same risks as any other major surgery, such as blood clots, and repeat C-sections can increase the risk of postpartum hemorrhage. To improve outcomes for birthing mothers at Benvenuto’s hospital, they focused on some of the highest-risk pregnancy conditions: hypertension/preeclampsia (dangerously high blood pressure) and postpartum hemorrhage. These are among the top contributors to maternal mortality. “We have educated our obstetrical care staff and emergency providers using evidence-based protocols and developed at-the-bedside tools to manage these conditions,” Benvenuto said. While it’s very tempting to want to compare birth outcomes across states, to say Alabama’s outcomes are significantly worse than Vermont’s–it’s

important to remember it’s not always a case of apples-to-apples, as it were. States face different challenges, and racism in particular (in health care settings and the accumulating toxic effects of everyday discrimination) can have an incredibly detrimental, even deadly, effect on the pregnancy and birth outcomes of black women. “When comparing states, you have to be careful. Unless you have many years of data, it can be tricky to compare. It’s disingenuous to compare a state with an almost completely white population to one with a large African American population,” said Dr. William Callaghan, chief of the Maternal and Infant Health Branch of the Division of Reproductive Health at the Centers for Disease Control and Prevention (CDC). Callaghan explains that the structure of segregated communities impacts how care is delivered: “Studies [have] found that outcomes of hospitals that primarily serve a black population are not the same as those that serve primarily white populations. The best levers, the best way to change those things, are people in the state realizing it’s happening. What has to happen is opinion leaders in communities driving change in how health care is delivered.” One big way Vermont’s maternity care stands out is just how many midwife-attended births there are. Nationally, midwives attend 10 percent of births. In Vermont, however, that rate is more than double: midwives attend a whopping 23 percent of births. The University of Vermont Medical Center has the only 24/7 certified nurse-midwifery practice in the region. Additionally, 67 percent of the state’s rural hospitals employ a nurse midwife—that’s practically unheard of in the U.S. Certified nurse midwives (CNMs) are people who’ve completed a nursing degree and midwifery training. Lay midwives, often called professional midwives or certified/licensed professional midwives must be licensed by the state in order to practice. Licensure requirements vary by state, but most

include the need to have completed a certain number of hours in midwifery training or apprenticeship and to have met the standard for certification by the North American Registry of Midwives (NARM). The state requires Medicaid to cover midwifery services by nurse midwives or licensed lay midwives. In states that do not regulate lay midwives, which means they do not offer licensure—effectively rendering lay midwives as illegal practitioners of health care—Medicaid would not cover lay midwifery services. Most nurse midwives tend to oversee births at hospitals, and occasionally at birthing centers, while lay midwives tend to births largely in homes and birthing centers. “Our practice is an integrated CNM/MD practice. We have three CNMs, three OB/GYN physicians, and a family medicine physician with additional training in obstetrics. We created a practice that elevates each clinician’s expertise,” Benvenuto said. “Our midwives provide the bulk of low-risk care, both for prenatal visits and on our delivery unit, and our physicians focus on complications of pregnancy and are always available for obstetrical emergencies.” Vermont is one of 25 states that allow CNMs to practice independently and exert full prescriptive authority. Nineteen states require them to enter into a collaborative agreement with a licensed physician and only practice under their direct supervision; the rest of the states allow CNMs to practice independently but must enter into an agreement with a doctor for prescriptions. Some argue supervision requirements facilitate cooperation among midwives and other health care providers, while others say it’s a paternalistic practice that stifles nurse midwives’ ability to practice freely and better meet the needs of their patients. The Birth Place Lab recently ranked states for midwifery access and integration. Vermont was ranked thirteenth in the nation. The state has an incredibly high density of midwives, which was associated with significant-

ly higher rates of spontaneous vaginal deliveries (as opposed to inductions), vaginal births after cesarean (VBAC), and breastfeeding, and significantly lower rates of preterm birth and low birth weight babies. Integration was based on how well these health care professionals were included in careprovider networks. “Interprofessional teamwork is essential to the provision of highquality maternity care,” the researchers declared. “When professionals collaborate on decision-making and when coordination of care is seamless, fewer intrapartum neonatal and maternal deaths occur during critical obstetric events. Poor communication, disagreement, and lack of clarity around provider roles are identified as primary determinants of these adverse outcomes.” Interestingly, the bottom seven least-integrated midwifery states were all ones requiring physician supervision of nurse midwives. In Vermont, the OB and midwife communities (both lay midwives and CNMs) typically work together very well. Some midwifery practices in the state see a nurse midwife and a professional midwife working together, which is rather unique. “We have cultivated relationships with homebirth providers in our area so there are seamless care transitions if women require intrapartum transport to our hospital or require consultation for high-risk conditions that may develop throughout their pregnancy. Our clinicians feel that this approach to care allows us to educate and empower women throughout their pregnancies and we are able to provide support throughout their labor process,” said Benvenuto. But like any other rural area, health care practitioners here face their share of challenges. “Practicing medicine in a rural area and in a smaller hospital, there are fewer resources. Whether it is a smaller clinician staff or nursing staff, we have to always be prepared to do more with less. We are on-call more frequently than our colleagues in big-

ger groups, which can lead to exhaustion and burnout,” Benvenuto said. “We also don’t have a blood bank or an ICU and the closest hospital with those services is 45 minutes away, so we have to be nimble, resourceful and be willing to work independently.” Adequate blood supplies for transfusions are essential for patients who experience hemorrhaging during childbirth. To address these varied challenges, Benvenuto says the first step is to transfer women who are likely to require high-risk care or early delivery are to the nearest tertiary care center. Vermont has been deeply affected by the opioid abuse epidemic. There’s also a shortage of mental health providers. Families also struggle with housing and food insecurity, leading to chronic stress from multi-generational poverty, and have difficulty making it to appointments because of transportation issues: no gas money, car troubles, single-car households. To address those challenges, Benvenuto’s medical group has created a Community Health team: a group of mental health and social workers. The team helps women find resources for basic needs like food, housing and transportation, and they also offer counseling that can be done in conjunction with their pre/post-natal visits. Benvenuto’s group has also begun providing Medication Assisted Treatment for opiate-dependent patients, which has helped reduce stigma and increased access to this much-needed treatment. “Working to alleviate these stresses has allowed women to better focus on caring for themselves and has been shown to increase compliance with prenatal care and improve pregnancy outcomes,” Benvenuto said. Other states should consider taking cues from Vermont’s efforts to collect data on maternal and child health outcomes and look for strategies to improve them, incorporate midwives into maternity care, and find ways to address community health challenges without increasing stigma.


SUMMER 2018 | RHQ   17

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20 Years of Telemedicine Regulation BY DAVA STEWART


or the last two decades, telemedicine has been hailed as either the answer to all of the woes facing rural health care or as the harbinger of the doom of health care. Both points of view have turned out to be extreme, and though most professionals in the health care industry now agree that telemedicine offers benefits to some populations that have historically had difficulty receiving adequate care, there are still hurdles to be overcome in order to fully realize those benefits. In the 1990s, most organizations interested in telemedicine faced the monumental task of convincing providers that it was a viable alternative. The gold standard was then, as it is now, in-person care. However, there are times an in-person visit isn’t possible, for a variety of reasons. Regulatory bodies were especially cautious, and with good cause. Patient safety, the reason that medical regulatory boards exist, is no small matter. In the beginning, many regulations that made sense in a face-to-face world hampered the successful delivery of telemedicine. Texas was, in some ways, a last holdout against telemedicine, but that changed in June 2017 with Senate Bill 1107, which abolished the requirement for patients and doctors to meet face-to-face prior to the delivery of care via telemedicine. Although there was a much-publicized lawsuit involving the Texas Medical Board and Teledoc, Scott Freshour, JD, Interim Executive Director of the Texas Medical Board stresses that the bill was a consensus bill. “All of the big stakeholders that have telemedicine interests in Texas were involved,” Freshour said, adding that the intention was to enhance

accessibility while ensuring patient safety. Considering the fact that Texas is a big state with some very rural communities, some of which are without physicians or are badly underserved, telemedicine seems like a natural fit, and SB1107 is likely to further encourage the use of the technology. Beyond eliminating the in-person requirement, the bill also updated the definition of telemedicine, allows for store and forward technology, and eliminated the need for a distant site presenter, which will allow for different types of technologies such as wearables to be used. Oregon, which also has many rural areas and difficult-to-serve populations, took a different approach in the early days of telemedicine. Nicole Krishnaswami, Operations and Policy Analyst with the Oregon Board of Medicine says that the state first created a special telemedicine license in 1999. “We were one of the first states to do this,” Krishnaswami said, “We further expanded that in 2004 and again in 2006 to include a bigger variety and more flexibility for people who want to do specific things.” As is the case with all medical boards, patient safety was the top priority in Oregon, and Krishnaswami says, “We feel very protective of Oregonians, whether they are poor or rural or imprisoned. We don’t set the standard any lower for providers working with those populations.” However, by embracing telemedicine technology from the beginning, and creating a framework for new ideas and new technology to be vetted and deemed appropriate, the state has increased access to care. “We have about 14,000 active physicians in the state of Oregon, and they can all use telemedicine. And we have almost 700 out-of-state providers who are licensed to use telemedicine,” says Krishnaswami. Parity, or equal compensation re-

gardless of how a service is delivered, is in some ways one of the last big barriers to the growth of telehealth programs. Currently, 33 states, including both Oregon and Texas, have telehealth parity laws. Care providers want to be compensated for their work, so parity in payment helps telemedicine programs expand because clinicians are more likely to participate if they know they will be paid. Along with parity, licensure has been a major barrier for telehealth providers. State medical boards control licensure and each one has its own set of requirements in order for a clinician to be licensed. In order to provide care, whether by phone, video, or in person, the clinician must be licensed in the state where the patient is located. For clinicians and telehealth providers working in multiple states, licensing can be expensive and complicated. The Interstate Medical Licensure Compact (IMLC) seeks to lessen the licensure burden by expediting the process. When a state agrees to join the Compact and the proper legislation is passed at the state level, physicians from that state can apply for licensure in any other state that is a member of the Compact relatively easily. The first licenses were issued through the Interstate Compact in April 2017. Currently, 22 states are involved, and of those eight are fully participating in the process, issuing both letters of qualification to physicians licensed in their state who wish to become licensed in others through the IMLC, and issuing licenses to those from other states. Another nine are issuing licenses, but not yet providing letters of qualification. In five others, the legislation has passed, but implementation has been delayed. The necessary legislation for state participation in the IMLC has been introduced in three other states, as well as Washington, D.C.


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THE AMES PROJECT // The “Ames Project� was a research and development project that was part of the larger Manhattan Project to build the first atomic bombs during World War II. Scientists purified bulk uranium and thorium, both radioactive metals, into purified forms that were then transported to the Fermi Lab at the University of Chicago, which was key in developing the atomic bomb.

public policy //

Rural Fallout Workers Exposed to Radiation During Arms Race Seek Compensation



oug Provaw, a 94-year-old who lives in Ames, Iowa, remembers receiving a chemistry set in the mail when he was in high school. A selfdescribed “science geek,” growing up in rural Iowa, Provaw said he was in “pig heaven” when the set arrived— replete with white phosphorus and a glass jar full of water. In hindsight, it was not the safest mail order, he said. “If the white phosphorus had had contact with the air, the set would have basically ignited.” In the 1940s and 1950s, chemistry was a more cavalier activity. In the 1960s, the U.S. Department of Labor began publishing profiles on dangerous chemicals, and safety data sheets. By the late 1980s, there were requirements for employers to provide information on chemicals used in the workplace. Provaw’s first job, much like his youthful forays into chemistry, predated these precautions. In 1951, he was hired as a nuclear materials accountant at the “Ames Laboratory” at Iowa State University in Ames. The laboratory fell out of the “Ames Project,” a top-secret wartime effort in which scientists purified bulk uranium and thorium, both radioactive metals, into purified forms that were transported to the famous Fermi Lab at the University of Chicago, which was key in developing the atomic bomb. After the war, the Lab’s reputation in handling rare metals increased, as did the pressure to produce nuclear reactors. Provaw was on the front lines of this production. He handled

thorium “bare-handed,” and recalls that a Geiger counter was used to record uranium levels. “We knew there were high levels of exposure,” he said. Workers also handled beryllium, a toxic alloy used in making nuclear weapons. They took certain precautions, like washing their work clothes at the lab instead of taking them home to be washed, Provaw adds, but that was done less as a safety measure than out of respect for the vow of secrecy workers were required to undertake. Several decades later, Provaw learned that he had chronic beryllium disease, an incurable condition caused by beryllium exposure that is classified as an occupational lung disease. Provaw’s 35 years of work at the Lab qualified him for federal compensation. The first step in compensation for many workers is a free medical screening through the Former Worker Medical Screening Program (FWP), established in the mid-nineties by the Department of Energy following a Congressional mandate. The Energy Employees Occupational Illness Compensation Program Act, started in 2000, has helped thousands of workers retroactively get compensation for conditions related to chemical and radiation exposure at nuclear weapons plants across the country. RURAL STRONGHOLD Middletown, Iowa, is a small farming community in a corner of Southeast Iowa that sits on the Mississippi River. The latest census data put the

population at 361. The town’s most notable feature lies just outside its limits—a sprawling Army Ammunitions plant established in 1940 by the Department of Defense. Initially it produced munitions and artillery for the war effort, and later, under the auspices of the Atomic Energy Commission, it carried out the final assembly of nuclear weapons during the Cold War. Like many ammunitions plants, its location was strategically rural— and bound by a river (and railway) for convenient transport of materials. A cemetery was overturned to build the site, and workers came from Iowa, Missouri and Illinois. “The weapons complexes were deliberately located in rural areas,” said Sarah Ray, whose husband Michael worked at the plant in the 1960s and 1970s. “Many people didn’t have enough land to be self-sufficient farmers. This gave them work. They were very patriotic. They had a strong work ethic.” They were also largely unaware of what they were handling—or at least very secretive about it, said Christina Nichols, who works with the FWP at the University of Iowa College of Public Health in Iowa City. “They had nicknames for everything, and they weren’t encouraged to talk to their co-workers about the work,” Nichols said. “There is a lack of institutional memory. Even today, one of the main security guards won’t say what he did there. He won’t file a claim,” she continued. “[Many workers like him] don’t want compensation because they say ‘it’s done, and

SUMMER 2018 | RHQ   21

we’d do it again.’” “Ames is a younger and more educated population,” Nichols added. Farm kids were recruited to work at the Ames Plant, but they generally had some knowledge of chemistry or engineering, with many graduate students in the mix as well. Ames was also where the trail of understanding about worker contamination began. A metallurgist at the plant, Norman Carlson, was diagnosed with chronic and acute berylliosis in the 1950s, explained Laurence Fuortes, the founding director of FWP at the University of Iowa. Around the same time, two Harvard professors and pioneers in occupational medicine—Alice Hamilton and Harriett Hardy—observed that toxins from factories were leaking into surrounding neighborhoods where there was a high incidence of lung diseases. The DOD followed up with studies on uranium, thorium,

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and beryllium, and clean-up efforts ensued in the 1960s, Fuortes added. But workers continued to be exposed to radiation in the decades that followed, suffering its lingering effects. Darwin Lewka, 95, an electronics technician who worked at the Ames Lab between 1966 and 1980, has skin cancer on the left side of his body. That’s the side that was exposed to more radiation since it faced the isotope separator in the reactor beam, he explained. He’s convinced that nine years of exposure (the nuclear reactor was decommissioned in the mid-1970s) took a toll on his body, contributing to two different cancers from which he’s suffered: stomach and skin. He filed compensation claims for both, and has received compensation for stomach cancer, while the other is still in process. Provaw also received $150,000 in compensation for beryllium

disease. “It was a lot of paperwork, but not hard,” he said. INVESTIGATIVE DOSE RECONSTRUCTION Compensation is not a seamless process for many people, however, and it used to be very challenging, when workers had to demonstrate the dose of radiation or exposure to chemicals they experienced. “It was almost impossible for workers to do, in places where they didn’t wear radiation film badges,” said Dan McKeel, a retired pathologist in the St. Louis area who helps workers with the compensation process. “In many instances, the plants didn’t keep the records, or intentionally destroyed them.” Also, the Department of Energy kept records on exposure to radiation, not toxic chemicals, he added, and hospitals weren’t required to keep medical records past five to

seven years. Disease latency—the lag time between initial causation and onset—was typically many years, too. “Since radiation damages DNA in only a few cells at first, by the time a cancer becomes clinically evident and produces symptoms, it’s probably been present for many years,” McKeel said, adding that it can be highly variable from one person to the next. “What’s true in one person will not be in the next. That’s an area we are still working on.” Tissues and organs also have different sensitivities to radiation, he added. For example, bone marrow, white blood cells, the lungs and thyroid are all very sensitive to radiation. To cut through all of these complicating factors, which often made the dose reconstruction process tedious and self-defeating, the Department of Labor created the Special Exposure Cohort, which automatically compensates workers at certain plants for work that took place during specific periods. Criteria at all plants includes demonstrated 250 days of employment, or a witness to that employment, and one of 22 cancers or other radiation or chemical-related diseases. At the Ames Lab, the qualifying years of employment are 1943-1989; and in Middletown, 1949-1974, when the nuclear weapons part of the Middletown plant closed. The plant still makes conventional munitions. The Ames Lab is still a research and development lab that does basic science research on materials and physical chemistry. In 1974, the nuclear weapons part of Iowa Army Ammunition Plant was transferred to the Pantex Plant near Amarillo, Texas. Ray, who lives in Amarillo, started helping people with the claims process after her husband, who also worked at Pantex (after Middletown) died of lung cancer, thought to be related to his work at both plants. The SEC qualifying years are 1951-1991.

Pantex Plant in Carson County, Texas is the primary United States nuclear weapons assembly and disassembly facility.

“I’ve helped thousands of people. I get one or two new requests each week. It’s never ending,” Ray said. “I see everything: skin cancers, breast and ovarian cancers, soft tissue cancers, gastrointestinal stromal tumors, lung issues of all types.” PROVIDING PREVENTIVE MEDICINE The first step in the compensation process is a free medical screening provided by the FWP program. As of September 2015, the nationwide program had conducted 119,512 exams. The most common health issue that emerged was asbestosrelated lung disease, affecting 12 percent of screened workers. Lung lesions, suspicious for cancer, accounted for another 3.8 percent. In Iowa, 16 percent of screened workers had findings that were suspicious for work-related lung disease. Iowa is one of four regional projects in which public health departments at universities conduct the screenings and help usher people through to the compensation program. Fuortes, who recently retired, is also a physician and screened personally thousands of workers. As of the end of March 2017, the Iowa program had screened 3,407 workers. This is

still only a little over 25 percent of the known living and eligible population. The program has mostly relied on word-of-mouth. They do monthly screenings in both plant locations and an average of 25 people show up each month. The screening consists of a medical history, a blood draw to test various conditions, including beryllium sensitivity (which qualifies them for automatic compensation); spirometry (which measures breathing patterns), urine and stool samples, a chest x-ray, and low-dose scans to detect lung cancer for people at high risk. Some people are then referred to specialists. Even if people don’t have workrelated conditions, many appreciate the free screening, Fuortes said. “We consider it a communitybased medicine program,” he said, adding that it has also become a form of preventive medicine for people who have been able to pick up on previously undetected conditions such as high blood pressure or diabetes. Jill Welch, the FWP Project Coordinator at Iowa, added, “Over and over, we hear, ‘That saved my life.' Most people are just so grateful. They say, ‘This has given me so much more time with my family.’"


SUMMER 2018 | RHQ   23

Making a Healthy Difference for Rural Texans

SERVING THE TEXAS RURAL HEALTH COMMUNITY The obstacles faced by health care providers and patients in rural areas are vastly different than those in urban areas. The Texas Rural Health Association (TRHA) is a nonprofit organization whose primary goal is to improve the health of rural Texans. Since 1984, individuals and organizations of TRHA have been dedicated to providing leadership on rural health care issues through advocacy, communication, and education.

THE TRHA MISSION  Promote rural health as a distinct concern in Texas.  Serve as a strong and unifying voice for concerned citizens,

community leaders, public officials, and health care providers and organizations working to improve rural health in Texas.  Advocate for rural health and promote an enhanced status

and improved health system for rural Texans.  Provide a forum for exchange and distribution of

information and ideas related to improvement of rural health.  Encourage the development of appropriate health resources

to all rural areas of Texas.

WWW.TRHA.ORG | 512-368-9860 | PO BOX 201363 AUSTIN, TX 78720


Amid Shortage, New AHEC Scholars Program Works to Recruit Rural Health


orkforce statistics, such as one conducted by the Physician Workforce in Texas Study, found that 35 counties in Texas did not have any physicians, 80 counties had less than five physicians, 185 did not have obstetric providers, 185 lacked psychiatrists and 158 had a shortage of surgeons. Debra Flores Another study DIRECTOR, WEST TEXAS by the North AHEC Texas Regional F. Marie Hall Institute for Extension Rural and Community Commission Health in 2015 also portrays a dim picture of the number of health care professionals available to take care of the health care needs in

Texas. This study found that the ratio of Nurse Practitioners in the United States is 60/100,000 population compared to the Texas ratio at 42/100,000. The ratio for Physician Assistants is not any better with the U.S. ratio at 42/100,000 compared to a Texas average of 33/100,000. The Robert Graham Center has also published a report projecting the rate of provider utilization and available workforce in the state. According to this study, Texas will need approximately 6,260 primary care providers by 2030. The health care provider shortage throughout the nation is a well-known fact, especially in rural communities, and new strategies and relevant solutions are required to fill the gap. To address this challenge, Area Health Education Centers (AHEC) across the country are implementing a new and innovative strategy beginning September 2018. With funding from the federal Health Resources & Service Administration Bureau of Health Workforce, AHECs all over America are rolling

out the National AHEC Scholars Program. The National AHEC Scholars Program is for health profession students interested in augmenting their education specifically in rural and underserved communities. The expectation from HRSA is for AHECs to develop training activities that will prepare students to address topics beyond what is taught in the classroom, such as interprofessional skills, cultural competency, health care transformation and social determinants of health. Additionally, the program plans to garner new partnerships and strengthen existing ones so that students are placed in rural and underserved communities for rotations. The National AHEC Scholars Program will require a three-year commitment from students. Two years will consist of a total of 80 hours of didactic and 80 hours of rotations in rural and/or underserved communities (40 hours for didactic and 40 hours for rotations per year). Community-based

Workforce Projections 2010-2030: To maintain current rates of utilization, Texas will need an additional 6,260 primary care physicians by 2030 (Robert Graham Center, 2013).

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to cover emerging topics. The following table describes the six core topic areas covered by the AHEC Scholars Program, ( (TABLE 2) TOPIC INTERPROFESSIONAL







Supports a coordinated, patient-centered model of health care that involves an understanding of the contributions of multiple health care professionals Promotes the development of integrated primary and behavioral health services to better address the needs of individuals with mental health and substances use conditions. Includes five key areas (determinants) of economic stability, education, social and community context, health and health care, and neighborhood and built environment, and their impact on health Seeks to provide students with tools to improve individual health and build health communities by training health care providers to recognize and address the unique culture, language and health literacy of diverse consumers and communities Aims to fully support quality improvement and patient-centered care through goalsetting, leadership, practice facilitation, workflow changes, measuring outcomes, and adapting organizational tools and processes to support new team-based models of care delivery. Students will learn about emerging topics such as Zika virus, opioid abuse, etc.

six core topic areas covered by the AHEC Scholars Program (SOURCE: The

The National AHEC Scholars Program will require a three year commitment from students. Two years

focus. Instead of recruiting students are shortages in other health care experiences are also interwoven will consist of a total of 80 hours of didactic and 80 hours of rotations in rural and/or underserved by providing health career presenta- professions, too. In Texas alone, within the curriculum. The third communities (40 hours for didactic and 40 hours for rotations per year). Community‐based experiences tions to large auditoriums filled with as many as 550 health profession year will be used to track the stustudents will be recruited into the every student in a school, AHEC is dent longitudinally post-graduation. are also interwoven within the curriculum. The third year will be used to track the student longitudinally AHEC Scholars Program to pursue moving to target the lateral end of Apost‐graduation. A study conducted by West Texas AHEC found that students who are placed in rural study conducted by West Texas careers in diverse health profesthe pipeline. The targeted students AHEC found that students who are rotations are three times more likely to practice in West Texas. Given this information, it is expected sions, including nurse practitioners, include grades 9-12 to collegiate placed in rural rotations are three that the strategy to place these scholars in rotations in rural and underserved communities will lead times more likely to practice in West students interested in health careers. physician assistants, occupational them to return to that community to practice which is one of the goals of the AHEC Scholars Program. therapists, physical therapists, counHigh school students are recruited Texas. Given this information, it is selors, licensed vocational nurses, to participate in programs such as expected that the strategy to place The AHEC mission to enhance access to quality health care by recruiting students into the health career registered nurses, social workers the Youth Health Service Corps, these scholars in rotations in rural and many other specialties. and underserved communities will the Scrubs Clubs and AHEC Jr. pipeline has narrowed the focus. Instead of recruiting students by providing health career presentations Scholars. These programs offer job AHEC’s new strategy is not an lead them to return to that comto large auditoriums filled with every student in the school from K‐12, AHEC is moving to targeted focus shadowing opportunities and tours immediate remedy for the nation’s munity to practice, which is one of different health career programs health care professional shortage, of the goals of the AHEC Scholars 2 along with other activities that will but the program is expected to Program. The AHEC mission to enhance lead students to decide which health begin bearing fruit in as little as two careers they will pursue. or three years. Interested applicants access to quality health care by Although primary care praccan learn more about the program recruiting students into the health titioners are badly needed, there at career pipeline has narrowed its


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Tuition-Free Med School Touches Off MultimillionDollar Debate BY JULIE ROVNER, KAISER HEALTH NEWS


ew York University’s School of Medicine is learning that no good deed goes unpunished. The highly ranked medical school announced with much fanfare Aug. 16 that it is raising $600 million from private donors to eliminate tuition for all its students — even providing refunds to those currently enrolled. Before the announcement, annual tuition was $55,018. NYU leaders said the move will help address the increasing problem of student debt among young doctors, which many educators argue pushes students to enter higher-paying specialties instead of primary care, or deters them from becoming doctors in the first place. “A population as diverse as ours is best served by doctors from all walks of life, we believe, and aspiring physicians and surgeons should not be prevented from pursuing a career in medicine because of the prospect of overwhelming financial debt,” Dr. Robert Grossman, the dean of the

medical school and CEO of NYU Langone Health, said in a statement. NYU declined a request to elaborate further on its plans. The announcement generated headlines and cheers from students. But not everyone thinks that making medical school tuition-free for all students, including those who can afford it, is the best way to approach the complicated issue of student debt. “As I start rank-ordering the various charities I want to give to, the people who can pay for medical school in cash aren’t at the top of my list,” said Craig Garthwaite, a health economist at Northwestern University’s Kellogg School of Management. “If you had to find some cause to put tons of money behind, this strikes me as an odd one,” said Dr. Aaron Carroll, a pediatrician and researcher at Indiana University. Still, medical education debt is a big issue in health care. According to the Association of American Medical Colleges, which represents U.S. medical schools and academic health centers, 75 percent of graduating physicians had student loan debt as they launched their careers, with a median tally of $192,000 in 2017. Nearly half owed more than $200,000. But it is less clear how much of an impact that debt has on students’

choice of medical specialty. The AAMC’s data suggests debt does not play as big a role in specialty selection as some analysts claim. If debt were a huge factor, one would expect that doctors who owed the most would choose the highestpaying specialties. But that’s not the case. “Debt doesn’t vary much across the specialties,” said Julie Fresne, AAMC’s director of student financial services and debt management. Garthwaite agrees. He said surveys in which young doctors claim debt as a reason for choosing a more lucrative specialty should be viewed with suspicion. “No one [who chooses a higher-paying job] says they did it because they want two Teslas,” he said. “They say they have all this debt.” Carroll questioned how much difference even $200,000 in student debt makes to people who, at the lowest end of the medical spectrum, still stand to make six figures a year. “Doctors in general do just fine,” he said. “The idea we should pity physicians or worry about them strikes me as odd.” Choice of specialty is also influenced by more than money. Some specialties may bring less demanding lifestyles than primary care or more prestige. Carroll said his surgeon father was not impressed when he opted

SUMMER 2018 | RHQ   27

for pediatrics, calling it a “garbageman” specialty. There is also an array of government programs that help students afford medical school or forgive their loans, although usually in exchange for agreeing to serve for several years either in the military or in a medically underserved location. The federal National Health Service Corps, for example, provides scholarships and loan repayments to medical professionals who agree to work in mostly rural or inner-city areas with a shortage of medical professionals. And the Department of Education oversees the Public Service Loan Forgiveness program, which cancels outstanding loan balances after 10 years for those who work for nonprofit employers. Medical schools themselves are addressing the student debt problem. Many — including NYU — have created programs that let students finish medical school in three years rather than four, which reduces the cost by 25 percent. And the Cleveland Clinic, together with Case Western Reserve University, has a tuition-free medical school aimed at training future medical researchers that takes five years but grants graduates who hold both a doctor of medicine title and a special research credential or master’s degree. This latest move by NYU, however, is part of a continuing race among top-tier medical schools to attract the best students — and possibly improve their national rankings. In 2014, UCLA announced it would provide merit-based scholarships covering the entire cost of medical education (including not just tuition, like NYU, but also living expenses) to 20 percent of its students. Columbia University announced a similar plan earlier this year, although unlike NYU and UCLA, Columbia’s program is based on students’ financial need. The programs are funded, in

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October 2017 Medical Student Education: Debt, Costs, and Loan Repayment Fact Card Class of 2017







Mean (indebted only)

$181,179 (↑0%)

$206,204 (↑1%)

$190,694 (↑1%)

Median (indebted only)

$180,000 (↑0%)

$202,000 (↑1%)

$192,000 (↑1%)




$100,000 or more




$200,000 or more




$300,000 or more




Pct. with Ed. Debt

Education Debt (including premed) of:

Planning to enter loan forgiveness/repayment program: Education Debt Breakdown


% Graduates


Premedical Education Debt



Medical Education Debt



Non-Education Debt

% Graduates


Credit Cards



Residency/Relocation Loans



Source: FIRST analysis of AAMC 2017 GQ data. Education debt figures include premedical education debt plus medical education debt. Non-education debt collected by category.

Cost, M1 In-State, 2017-18



Median Tuition & Fees

$36,937 (↑1%)

$59,605 (↑4%)

Median Cost of Attendance (COA)

$60,945 (↑3%)

$82,278 (↑2%)

Median 4-Yr. COA for Class of 2018 $243,902 (↑1%) $322,767 (↑3%) Source: AAMC TSF Survey data from 88 public schools and 54 private schools.

whole or in part, by large donors whose names brand each medical school — entertainment mogul David Geffen at UCLA, former Merck CEO P. Roy Vagelos at Columbia, and Home Depot co-founder Kenneth Langone at NYU. Economist Garthwaite said it is all well and good if top medical schools want to compete for top students by offering discounts. But

if their goal is to encourage more students to enter primary care or to steer more people from lower-income families into medicine, giving free tuition to all “is not the most targetefficient way to reach that goal.”


Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.

Webside Manner As telemedicine goes mainstream, medical school education is scrambling to catch up. BY BARBARA MANTEL


In the frontier state of Montana, where kids are taught from a young age to “cowboy up,” suicide has a stranglehold on its people. Residents, many of whom live in isolation, are killing themselves at a rate faster than almost any other place in the nation. Mental health, public health and even government 30  RHQ | RuralHealthQuarterly.c officials are scrambling to find a way to halt what has been deemed a crisis.

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Summer 2017 | RHQ   31

SUMMER 2018 | RHQ   31



sychiatrists at the University of Virginia counsel adults and children throughout the state using videoconferencing. Nurses at FirstHealth Home Care in North Carolina use wireless blood pressure cuffs to remotely monitor patients recently discharged from the hospital. And emergency medicine physicians at Avera Health, a regional health system based in South Dakota, provide real-time emergency consultations to more than 100 distant community hospitals. The use of telemedicine is on the rise. Nevertheless, widespread adoption is lagging despite advances in technology and demonstrated benefits, according to the Center for Connected Health Policy, a research organization. For example, fewer than a quarter of rural family physicians responding to a recent survey said they use digital technology to connect to specialists or to communicate with far-flung patients. Inconsistent insurance reimbursement, limited broadband access and varying cross-state licensing laws are some well known barriers to implementing telemedicine, and states and the federal government have begun to address those issues. Less discussed is the lack of formal education in telemedicine for physicians-intraining. The Association of American Medical Colleges (AAMC) found in an annual survey that 84 out of 145 medical schools said they included telemedicine as a topic in either a required or an elective course in the 2016-2017 academic year. But that could mean almost anything, from a brief mention of telemedicine in a lecture to fullfledged simulations of remote patient care. The survey does not ask for details. “The types of experiences that schools offer students range as widely as the penetration of telemedicine clinical services

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themselves,” says Dr. Scott Shipman, AAMC’s director of clinical innovations. Robust telemedicine training at medical schools and in residency programs is far too rare, says Dr. Susan Skochelak, group vice president for medical education at the American Medical Association. Yet such programs are necessary if the majority of physicians are to become comfortable practicing telemedicine, she says. “You can’t assume that [medical students and residents] are going to learn it once they get out in practice. It’s too important,” says Skochelak. In 2016, the AMA adopted a new policy encouraging accrediting bodies for both medical school and residency programs to include core competencies for telemedicine. “But the main thing that we have done at the AMA is, within our consortium of medical schools, to showcase this as a topic to other medical schools,” says Skochelak. Since 2013, the AMA has been working with leading medical schools – the consortium now totals 32 members – to bring medical school education into the 21st century, awarding them a total of $12.5 million in grants to create innovative programs. The University of North Dakota School of Medicine and Health Sciences joined the consortium in 2016 with a project to develop comprehensive telemedicine training. “We told the AMA that we were not doing this as a proof-ofconcept. We were going to integrate this into the school’s curriculum,” says Richard Van Eck, PhD, the associate dean for teaching and learning. In other words, it would be mandatory for every medical student. “We don’t think you can prepare medical students, certainly not for North Dakota, which is primarily rural, without focusing on telemedicine,” says Van Eck, who adds that an important component of the program is to train students across

healthcare professions to work together as a team. Second-year medical students, along with nursing, occupational therapy, physical therapy and social work students—274 students in all—went through the first training, which took place in November and December. In the school’s simulation center, the students moved through three scenarios involving “Sandra,” a patient played by a hightech manikin or a scripted volunteer. In the first scenario, Sandra arrives in the emergency room with chest pains and shortness of breath. The medical and nursing students use a computer tablet mounted on a motorized pedestal to videoconference with a cardiologist, who is using a computer in another room. Heart monitors and other devices are wirelessly connected to the tablet. Sandra is diagnosed with myocardial infarction, drugs are ordered and she eventually has a stent placed. In the second scenario, Sandra does not have cardiac rehabilitation in her small town and insists on going home. Nursing, occupational therapy, physical therapy and social work students join Sandra and a family member, played by a volunteer, to videoconference with her physician—a medical student—over laptops. They determine she needs to be moved to long-term care. In the third scenario, social work and nursing students, along with family members, use a laptop to teleconference with a medical student about end-of-life planning. Throughout the process, the students are learning skills that are unique to telemedicine, such as establishing rapport over the internet with both patients and specialists, and they found it a lot more difficult than they had anticipated, says Van Eck. When consulting with the cardiologist, the students did not always position the camera so that the cardiologist could see all the members of the team and understand who

was talking. They forgot to adjust the volume. They had distracting sidebar discussions, ignoring the cardiologist, “which you tend to do when somebody is at a distance,” says Van Eck. When speaking remotely to family members and the patient in the last two scenarios, the students had to remember to fill the screen with their face, to maintain eye contact and to not constantly look down at their notes. “When you are trying to explain things to people who are frightened by the possibilities, it’s hard to do in the best of circumstances, and telemedicine makes it even harder,” says Van Eck. Other comprehensive telemedicine training can be found at academic health systems that have a long history of using telemedicine with their patients, such as the University of California, Davis, says Shipman. However, they appear to be mostly electives. At the UC Davis School of Medicine, about 20 percent of students are enrolled in three community health scholars programs—one focused on rural health, one on the majority-rural San Joaquin Valley and one on the urban underserved population—and they receive telemedicine training in their first and second years. At the school’s telehealth center, the students move through mock cases with a volunteer “patient” operating from a script and a remote specialist, with whom they communicate through a computer equipped with a camera and attachments,

such as a stethoscope to hear the heartbeat, a microscope to look at skin lesions and an otoscope to see the inner ear. In addition to learning so-called website rapport with patients and families and how the technology works, these students learn how to clearly and concisely ask questions of specialists, says Dr. Blanca Solis, the director of the school’s pre-clinical curriculum. “Telehealth is a challenging medium, and when you are reach-

ing out to someone who may be in the middle of a busy day, it’s best to be prepared to present information concisely,” says Solis. “We’ve heard from specialists that, over time, providers using telehealth learn to anticipate what the specialist may want to know or what labs they need to have prepared.” It would be better if they could learn that skill while in school, she says. And for the rural health scholars, Solis says the training has another goal: to keep them interested in rural health as they move through medical school. “By exposing them

early to telehealth, they get to see that they won’t be alone in a rural practice, that they have these means to reach out.” The school has considered expanding the training to other medical students, but it is logistically challenging to coordinate the schedules of specialists, faculty, standardized patients and students, says Solis. “I think reaching 20 percent is pretty good,” she says. Coordinating schedules is just one barrier to implementing telemedicine training in medical, nursing and other health professional schools. Finding specialists experienced in telemedicine to help develop the curriculum and teach it and finding money in the budget for equipment are two others. Perhaps the biggest barrier is finding time inside an already packed curriculum. But it can be done, says Van Eck. The University of North Dakota plans to expand its training into simulations of other chronic diseases, such as diabetes management and mental health. “My guess is that threequarters of our simulations will eventually have telemedicine in them,” Van Eck says. Adding it to the simulation on heart disease “was a lot easier than we thought it would be, although it took a lot of time and work to figure that out.” He and his colleagues would like to save other medical schools that time and work. They have proposed to the AMA that they write a toolkit about how to integrate telemedicine into medical curriculum scenarios. “Learning telemedicine on the fly, as doctors, is not the responsible thing,” says Van Eck. “We need to start that earlier.”


SUMMER 2018 | RHQ   33

Health TechNology //

Four Keys to Telemedicine Etiquette



Never assume that your videoconferencing equipment is off – always check the equipment, use a lens cover, and have your device set to auto-mute on answer, to avoid accidental HIPAA violation. Consider the use of headphones instead of loud computer speakers so that protected health information is not overheard outside your office.


lthough a good “bedside manner” comes as second nature for most clinicians, conveying concern and competency over the “wire” of telemedicine can be challenging. Here are four simple tips to deliver outstanding care through a videoconferencing connection: 1. VISUAL AWARENESS Use a self-view on your own monitor so that you can see what you look like to your patients. Is your camera angle unflattering? Put the webcam at eye-level or slightly higher to avoid a view of your double chin. What about the light source? A window behind you may cause you to look like a silhouette. Use a lamp in front of you so the patient can read your non-verbal cues. 2. AUDIO CLARITY Speak clearly and maintain an even volume when speaking. Always assume the microphone is on, and do not say anything that you don’t want everyone to hear. Most microphones are very sensitive and can pick up the sounds of typing, papers shuffling, or jewelry clanking on a desk. Do your best to minimize all distracting noises.

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4. INTERPERSONAL COURTESY It may be tempting to multitask when you are sitting in front of a computer. Don’t. Avoid distractions such as side conversations, cell phone calls, or checking emails while the patient is connected with you. Set your devices to “do not disturb” and treat the visit as you would an in-person consultation. Make every effort to look at the webcam often (not the person on the screen) to give the impression that you are looking them in the eye. For more Do’s and Don’ts to make your telemedicine program a success, consider a professional training program. The Frontiers in Telemedicine training program in ( focuses on competency-based learning and is designed for licensed healthcare professionals, including mental health professionals, nurses, nurse practitioners, physician assistants, residents, and medical doctors who desire to learn about the procedures, technology, and business of telemedicine.


Learn telemedicine clinical presenting procedures, technology, and business!

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Live Lectures and Equipment Demonstration

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At the end of this course, the student should be able to demonstrate:  basic knowledge of Telemedicine/Telehealth and define those who could benefit from this technology  knowledge of the Originating/Distant site, as well as the clinician/staff roles at each one  ability to operate certain telemedicine technologies  knowledge of the procedures for a telemedicine encounter  utilization of knowledge required to present and manage the patient through telemedicine  application of communication skills in patient and medical team communication


There's An Illegal Market For An Opioid Addiction Medication. Is That Such A Bad Thing? BY JAKE HARPER, SIDE EFFECTS PUBLIC MEDIA


onths in prison didn’t rid Daryl of his addiction to opioids. “Before I left the parking lot of the prison, I was shooting up getting high,” he says. Daryl has used opioids such as heroin and prescription painkillers for more than a decade. Almost four years ago, he became one of more than 200 people who tested positive for HIV in an historic outbreak in Scott County, Indiana. He went on a bender after his diagnosis, he says. But about a year ago, Daryl had an experience that made him realize he might be able to stay away from opioids. For several days, he says, he couldn’t find drugs. He spent that time in withdrawal. “It hurts all over. You puke, you get diarrhea,” Daryl says. But his best friend offered him part of a strip of Suboxone, a brand name version of the addiction medication buprenorphine, a long-acting opioid prescribed for people who are addicted to heroin or other opioids. The medication reduces cravings and prevents withdrawal. Daryl says he injected it and his symptoms disappeared. Daryl is his middle name, which Side Effects is using to protect his identity because it’s illegal to use buprenorphine without a prescription. “I didn't crave nothing. I wasn't sick. My belly didn't hurt. I wasn't hurting in my joints,” he says. Weeks later, Daryl again struggled to find drugs, and the grind of daily opioid use had worn on him. He

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Daryl and Anne injected Suboxone, a brand name addiction medication, to stay away from illicit drugs such as heroin and fentanyl. CREDIT SETH HERALD FOR SIDE EFFECTS

didn’t want to spend the rest of his life on heroin. He could easily find buprenorphine in his area, and it lasted longer. He decided to use it on a regular basis, which he says reminded him of his life before opioids. “At first it felt like I was high,” Daryl says. “But I think that’s what normal feels like now. I have not been normal in a long time.” Buprenorphine is one of just three federally approved medications to treat opioid addiction. It’s possible to misuse it because it’s an opioid itself — people snort or inject the medication to get high. And patients with prescriptions can sell or give it away, which is known as diversion. Some policymakers and officials, such as Kentucky Attorney General Andy Beshear, point to diversion as a reason to regulate buprenorphine prescribers more, and they compare some buprenorphine providers to “pill mills,” stand alone pain clinics that are seen as a contributor to the opioid epidemic. "This is a drug that, if used in the right way, can be a positive," Beshear told NPR last year. "We worked so hard to shut [pill mills] down. If we can't learn from our past and make sure we don't repeat those mistakes,

then shame on us." Beshear's office did not immediately respond to a request for comment. But addiction treatment professionals argue the problem of buprenorphine diversion is often misunderstood. The black market exists, in part, because addiction treatment can be hard to find, and the availability of the drug on the street can be helpful, they say. WEAKER EFFECTS Dr. Kelly Clark, president of the American Society of Addiction Medicine, says for one thing, buprenorphine is not as dangerous as other opioids. “We care about diversion from a public health standpoint because of the risks of overdose, and the risks of overdose with buprenorphine are minimal,” she says. Buprenorphine’s effects are less potent than those of heroin and fentanyl, and the medication can block other opioids. It can even cause the onset of withdrawal symptoms if taken too soon after another drug. It is possible to fatally overdose from buprenorphine — especially if people don't have a tolerance to opioids or they mix it with other

substances — but it’s rare. Nearly 1,600 people died of opioid-related overdoses from 2010 to 2017 in Marion County, Indiana, where Indianapolis is located. But just 12 people died with buprenorphine in their system, according to data from the coroner’s office. The office blamed just one death on buprenorphine alone. Buprenorphine’s attributes mean few people use it to get high. There’s research to back that up, and the medication is often formulated with naloxone, which reverses opioid overdoses. That reduces its appeal as a recreational drug. Instead, more people use it to prevent withdrawal, and to try and stay away from other illegal drugs like heroin and illicit fentanyl. Some addic-

tion experts argue that self-treatment with buprenorphine can reduce harm because it’s used in place of more dangerous substances that are blamed for the continued rise in overdose deaths. “It was not diverted buprenorphine that's responsible for our current situation,” says Dr. Zev Schuman-Olivier, an addiction specialist and instructor at Harvard Medical School. “The majority of people ... are using it in a way that reduces their risk of overdose.” “It's definitely illegal,” says Daryl. “But would they rather me be driving to Louisville and picking up two eight balls of heroin?” LIMITED ACCESS Dr. Michelle Lofwall, an addiction

specialist and researcher at University of Kentucky, says people often try to treat themselves when they struggle to get into real treatment. “These people want help, and they tried and they didn’t succeed. So now they’re going to go get it if it’s available,” she says. Professional treatment with buprenorphine can be hard for patients to get. Prescribers must get a special waiver to prescribe the medication, and still only a fraction of doctors take that step. And federal rules limit the number of people they can treat, a cap that is unique to buprenorphine. Policymakers have debated expanding access to the drug in recent years to help curb the opioid epidemic. Federal guidelines changed under the Obama administration to

Data from the National Forensic Laboratory Information System indicate that buprenorphine seized in drug cases has increased since its introduction in 2002, but still only 1 percent of drugs seized in 2016 were identified as buprenorphine. CREDIT NATIONAL FORENSIC LABORATORY INFORMATION SYSTEM 2016 ANNUAL REPORT

SUMMER 2018 | RHQ   37

increase the number of prescribers and the number of patients they can treat. Nurse practitioners and physician assistants can now apply for a waiver to prescribe buprenorphine. And doctors who meet certain requirements can now treat up to 275 patients, instead of the previous limit of 100. This year, the U.S. House of Representatives passed legislation to allow some advanced practice nurses to prescribe buprenorphine. The Senate has yet to act on that proposal. Law enforcement officials and other policymakers point to cashonly buprenorphine clinics as drivers of diversion. Some buprenorphine clinics don't take insurance, which makes treatment expensive for patients. It can cost hundreds of dollars a month, so a patient may sell part of their prescription to afford their care. And such clinics may offer lower quality treatment because they don’t have to adhere to rules imposed by insurers. For instance, some insurers require that patients receive counseling to get a buprenorphine prescription. Critics say that more regulation and enforcement actions are needed to stop such operations. For instance, Indiana’s attorney general supported legislation this year to add regulations to buprenorphine prescribers in the state, although the legislation ultimately failed. Basia Andraka-Christou, an assistant professor and addiction policy researcher at the University of Central Florida, concedes that cash-only buprenorphine prescribers may offer lower quality care. “You have a bit of a hierarchy in my experience,” she says. But increasing regulations or shutting prescribers down would limit treatment options for people with opioid addiction, Andraka-Christou says. “I guarantee you, they're either going to go and buy heroin and get high, which surely is not a great

38  RHQ |

Staff at CleanSlate, an addiction treatment center in Anderson, Ind., test urine and count Suboxone wrappers from patients to make sure they adhere to their buprenorphine regimen. CREDIT JAKE HARPER / SIDE EFFECTS

policy solution here,” she says. “Or they're going to go buy Suboxone on the street.” REAL TREATMENT This street treatment is not ideal. Patients need a treatment professional to help them figure out the right dose and to address other mental health needs that are common among people with addiction. But Lofwall says people will often realize they want professional help after trying the medication illegally. “They've had it and they know it works for them and they want to get it legally,” says Lofwall. “They want to get their life back.” Daryl had a similar experience. Several weeks after he began using buprenorphine regularly, Daryl

tried to sign up for insurance so he could get help. “I think if I had never started [Suboxone] on the street... I wouldn't have no interest in doing nothing but getting high,” he says. He still hasn’t made it into treatment. He had trouble starting his insurance, and the market for illicit buprenorphine can be fragile. Daryl struggled to stay away from heroin when the person he bought buprenorphine from lost their prescription. Addiction can take years to conquer, but Daryl says his time on buprenorphine allowed him to see a way back to a normal life. “I'm at a point of my life now where I know I've got to change something, or I'm going to go back to prison,” he says. “I'm definitely ready to do something different.”


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heck out our list of rural health conferences, and let us know if you’re hosting one so we can help spread the word. Email us the details at Rural Health Clinic Conference September 25-26, 2018 Sheraton Kansas City Hotel at Crown Center, 2345 McGee Street Kansas City, MO Rural Community College Alliance Conference September 25-27, 2018 DoubleTree by Hilton Hotel Park City, 1800 Park Ave. Park City, UT Critical Access Hospital Conference September 27-29, 2018 Sheraton Kansas City Hotel at Crown Center, 2345 McGee Street Kansas City, MO New York State Association for Rural Health Conference September 27-29, 2018 Greek Peak Mountain Resort, 2000 NY-392 Cortland, NY Rural Minnesota Community Health Worker Conference September 28, 2018 Hampton Inn and Suites, 1019 Paul Bunyan Dr NW Bemidji, MN Oregon Rural Health Conference October 3-5, 2018 The Riverhouse 3075 N. Business 97 Bend, OR

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Association of Programs for Rural Independent Living Conference October 5-8, 2018 Renaissance Denver Stapleton Hotel, 3801 Quebec Street Denver, CO

South Carolina Rural Health Conference October 8-10, 2018 Embassy Suites Myrtle Beach Oceanfront Resort, 9800 Queensway Blvd. Myrtle Beach, SC

Rural Health Association of Tennessee Annual Conference November 14-16, 2018 Music Road Resort Hotel and Inn, 314 Henderson Chapel Rd. Pigeon Forge, TN

West Virginia Rural Health Conference October 17-19, 2018 Pipestem Resort State Park, 3405 Pipestem Drive Pipestem, WV National Association of Rural Health Clinics Fall 2018 Institute October 23-25, 2018 Hyatt Regency Lake Tahoe Incline Village, NV

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