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NYSARH submits testimony to the NYS Assembly Health Committee Public Hearing on Rural Health.

Below is the testimony submitted to the Assembly Health Committee Public Hearing on Rural Health Care Services on May 31st.

The New York State Association for Rural Health (NYSARH) is a not-for-profit, non-partisan, grassroots organization working to preserve and improve the health of the citizens in rural New York State.  NYSARH was founded in July 2001. The organization is affiliated with the National Rural Health Association.

The mission of NYSARH is to improve the health and well-being of rural New Yorkers and their communities.

NYSARH is a membership organization. NYSARH membership includes representatives of all facets of the rural health care industry, as well as individuals and students.  NYSARH serves individuals, consumers, non-profit organizations, government agencies and officials, health care facilities, emergency medical service providers, long-term care organizations, businesses, universities, foundations, associations, and other stakeholders in rural health.

New York State defines a county as being rural if it has a population of less than 200,000.  More than two thirds of all New York Counties are classified as rural. The scope of NYSARH includes all forty-three rural counties in New York State.

  • Fewer than 50,000 residents: Allegany, Cortland, Delaware, Essex, Greene, Hamilton, Lewis, Orleans, Schoharie, Schuyler, Seneca, Wyoming, Yates
  • 50,000 – 100,000 residents: Cattaraugus, Cayuga, Chemung, Chenango, Clinton, Columbia, Franklin, Fulton, Genesee, Herkimer, Livingston, Madison, Montgomery, Otsego, Putnam, Steuben, Sullivan, Tioga, Warren, Washington, Wayne
  • 100,000 – 200,000 residents: Chautauqua, Jefferson, Ontario, Oswego, Rensselaer, Lawrence, Schenectady, Tompkins, Ulster

NYSARH appreciates this opportunity to provide testimony to the NYS Assembly.  We thank you for your work to enhance the health and well-being of all New Yorkers.

NYSARH members collaborate within their distinct rural communities to promote healthy communities, improve access to healthcare and address factors known as social determinants of health, many of which are highly correlated with poverty.

NYSARH works to build integrated systems of patient-centered care serving rural communities.  As an association, NYSARH collaborates with county governments, statewide colleagues from similar associations, and with our counterparts in other states.

Rural Americans are a population group that experiences significant health disparities. Health disparities are differences in health status when compared to the population overall, often characterized by indicators such as higher incidence of disease and/or disability, increased mortality rates, lower life expectancies, and higher rates of pain and suffering. Rural risk factors for health disparities include geographic isolation, lower socioeconomic status, higher rates of health risk behaviors, limited access to healthcare specialists and subspecialists, and limited job opportunities. This inequality is intensified as rural residents are less likely to have employer-provided health insurance coverage.

The harm to rural communities from the 2017-18 funding reduction to public health programs was real and exceedingly illogical given the fact that these organizations work directly and measurably to support the NYS Prevention Agenda.

Results of a NYSARH-conducted survey found that as a result of the funding cuts to rural programs, independent rural healthcare and public health organizations implemented layoffs, program cuts and reduced community engagement after those funding cuts.  Further, we found indicators of harm to the rural populations we serve through loss of education, outreach, access, transportation, workforce development, and addiction prevention programs.  The damage to local economies by these funding cuts amplified the negative effects of pre-existing health disparities and negative social determinants of health in these communities.

Additionally, the cuts harm the economies of rural communities and their ability to leverage funding for other essential programs.  NYSARH research conducted with the assistance of a Rural-PREP Micro research grant demonstrated that for every dollar lost to community rural health programs, those communities lost approximately $1.50 worth of economic activity.  New York’s rural regions cannot easily withstand erosion of their economies.

For more information please view the video:  https://vimeo.com/313195728

 Regarding the areas of interest outlined in the notice for this Hearing we offer the following:

Emergency and Non-Emergency Transportation

  • NYSARH supports rural public transit systems
    • Rural transportation subsidy was discontinued
    • Allow Medicaid to be used for bus passes
    • NYS should support volunteer driver programs
  • NYSARH supports EMS/Ambulance reforms

The fact that Emergency Medical Services are classified as transportation is the where reform needs to begin.  Especially in rural communities, medical response to an acute illness or injury begins with the call to a trained 911 dispatcher.  When the ambulance arrives, it is staffed with highly trained emergency medical professionals who provide essential pre-hospital care on the scene and on route to a hospital, which may be as much as an hour away.

EMS providers are first responders, similar to police and fire fighters, and are frequently part of an emergency response teams with local police and fire units.  It is time for New York to systematically reframe its approach to EMS.

  • Many Rural EMS agencies depend on volunteers to provide life-saving services
    • 24/7/365 coverage
    • Training requirements are stringent, time-consuming and expensive
    • NYSDOH training reimbursement has been flat since 1999
  • It is time to increase the training subsidy and structure it to keep pace with costs
    • NYSDOH training reimbursement covers less than half the actual cost of training. Volunteer EMS providers must cover the remaining expense.
      • For example: Upstate Medical University is a DOH-approved course sponsor. They offer a paramedic class that requires students to complete 500 hours of classroom training plus an additional 500+ hours of internship and field training.
        • 2019-2020 Course Tuition and Fees: $5,865.
        • NYS DOH will reimburse only $1,500.
  • Insurance reimbursement for EMS is inadequate and is jeopardizing the financial viability of rural EMS agencies:
    • Medicaid’s own research determined that payment rates do not cover actual costs
    • NYSARH encourages DOH to develop new codes to recognize a range of pre-hospital medical services offered by EMS providers that may be reimbursed by private insurers, as well as Medicaid and Medicare

Workforce Development, Recruitment & Retention. Highly compensated specialists, primary care physicians, nurses and other clinicians are in demand and can go anywhere.  Consistent supportive strategies are needed to encourage them to serve our rural communities.

  • NYSARH supports existing workforce programs, including:
  • Rural Area Health Education Center (AHEC) System
  • Doctors Across New York—Support New York’s budget proposal to ensure a new cycle of up to 75 awards for physicians in Health Professional Shortage Areas.
  • Rural Medical Education Program (RMED), which pairs third-year students with board-certified family physicians in rural communities.

New York should establish a clinical preceptorship personal income tax credit for certain health care professionals who provide preceptor instruction to students.  This has been done successfully in other states.

  • Professional shortages exist at all levels
    • New York makes it difficult for professionals licensed or certified in other states to practice here; this process needs to be much simpler and faster
    • Priority Disciplines:
      • Psychiatrists
        • All behavioral health practitioners
      • Obstetricians
        • Midwives
      • Primary Care Physicians, MD and DO
        • PA/NP
      • NYSARH member organizations also struggle with recruitment and retention of paraprofessionals who care for and support people in long-term care, disability services and behavioral health.

  Rate Adequacy for Low-Volume Providers

  • NYSARH supports continuation of the following programs that support Rural Providers
    • Rural Health Access Development
    • Rural Health Network Development
  • The federal government supports rural healthcare through a variety of programs [critical access hospitals, 340B pharmacy discount program, etc.] NYSARH encourages NYS to advocate for and actively support these programs.
  • Oral health is much more significant than many people realize; yet Medicaid reimbursement rates for dental care are so inadequate, most dentists refuse to participate in the program. We urge you to seriously re-evaluate funding for oral healthcare for children, adults and older adults.
  • Capital funding continues to be needed for distressed safety net providers, including Vital Access Provider funding for rural and Critical Access Hospitals and dedicated funding for Sole Community Hospitals; continued support for previous commitments for Health Care Facility Transformation Program and flexibility in allocation of funds.
  • According to a Chartis/iVantage analysis of current health policy on rural hospitals and communities commissioned by the National Rural Health Association, among rural hospitals in New York State:
  • The median operating profit margin is .5 percent;
  • Forty-eight percent have a negative operating profit margin; and
  • Thirty-eight percent of rural hospitals have an operating profit margin below -3 (negative three) percent.

NYSARH would like to bring these additional topics to the attention of the Committee:

Collaborative Community Engagement for Rural Health

  • The 2017-18 NYS Budget slashed funding for several community-based, public health, health education and rural health programs by 20%-22%.
    • NYSARH appreciates the Legislature’s refusal to repeat this strategy, which was proposed in the Executive Budget for 2018-19.
    • The 2017-18 funding reduction remains, and has been ‘baked in’ to contracts with NYS including the 2019-2023 contracts for Rural Health Network Development.
    • These contracts do not include annual increases. This is effectively an annual 2% to 3% cut compounded over the five-year contract.
    • NYSARH supports restoration of the 2017-18 funding cut. There is a continued need for restoration to 2016-17 levels of funding ($9.8 million) for Rural Access and Development and Rural Health Networks ($6.4 million).

Population Health

NYSARH advocates for solutions that consider the impact of Economic Development on Health.

The National Advisory Committee on Rural Health and Human Services is a good resource for additional information regarding rural health disparities.  www.hrsa.gov/rural-health/  The Committee has consistently documented the unique health barriers experienced by individuals residing in rural areas.  Barriers include inadequate access to primary and behavioral health care, rural hospital closures, health professional workforce shortages, lack of transportation services, food insecurity, housing instability, and diminished economic opportunities. Compounded by the already limited rural infrastructure, each of these determinants contributes to existing rural health disparities, which in turn, have a negative impact on rural life expectancy, morbidity, and mortality. The Committee’s past work has focused on understanding how conditions and outcomes such as homelessness, childhood poverty, intimate partner violence, opioid misuse, suicide and adverse childhood experiences can be mitigated or more effectively addressed through health and human service programs.

  • NYSARH supports the NYS Prevention Agenda Programs, including:
    • Safe, affordable and accessible housing, including lead abatement
    • Collaborative Community Health Assessment/Community Health Improvement Plan (CHA/CHIP)
    • Population Health Improvement Program (PHIP)
  • Chronic disease is the largest driver of healthcare costs; there is a need for continued funding for:
    • Chronic disease management and prevention, including diabetes prevention and chronic pain self-management programs.
    • Obesity & Diabetes Prevention
    • Hypertension Prevention
    • Smoking & Vaping Prevention

Access to Care

  • NYSARH is concerned about the sustainability of Rural Health Providers including hospitals, health centers and primary care providers. A recent study of the financial viability of rural hospitals nationwide showed 21% or 430 hospitals across 43 states are at high risk of closing unless their financial situations improve. Per capita income falls 4% and the unemployment rate rises 1.6 percentage points when a hospital closes.
    • In New York, few stand-alone rural hospitals and health centers still exist. Most have already joined with large multi-site health systems.  NYSARH hopes to ensure that the business viability of these rural locations remains strong enough for the health systems to keep them operational.
  • New York has done a terrific job implementing the Affordable Care Act and the New York State of Health insurance marketplace.
    • Even so, many New Yorkers are under-insured due to the prevalence of high co-pays and high deductibles, including many with employer-subsidized coverage
    • These out-of-pocket costs influence people’s decisions to seek timely and appropriate healthcare.

 Telehealth/Telemedicine

  • NYSARH supports regulatory consistency among DOH/OASAS/OMH/OPWDD
    • Though there has been improvement in this area, licensure, certification and credentialing inconsistencies continue to create barriers to integrated person- centered care.
  • Telehealth parity. Payment for Telehealth/Telemedicine is still an issue; rates are inadequate for maintenance and provision of services, or not available
    • Medicaid
    • Private Insurance
  • There is a need for $5 million in funding for Regional Perinatal Centers and other healthcare providers to establish telehealth capabilities.

Behavioral Health/Mental Health/Suicide Prevention

  • Rural communities struggle with behavioral health issues
    • Strengthen existing substance use and mental health programs
      • NY Farm Net
      • Programs for Veterans
      • Support peer-to-peer models

Thank you for expanding the Joseph Dwyer Peer-to-Peer program.

  • Need to bolster existing substance use disorder and behavioral health treatment programs
    • Cost of living adjustment funding
    • Opportunities for expansion
    • Capital funding
  • Address the addiction crisis. Along with opioids, larger health risks to rural communities include:
    • Methamphetamine: making an alarming come-back
    • Vaping: considered by prevention professionals as the greatest risk to our youth.
    • Alcohol and tobacco: still the largest substance risks in our communities

Thank you for passing the Tobacco 21 initiative.

  • NYSARH appreciates the funding for services added in recent years to address the opioid epidemic in New York State. However, much of the new funding has not supported the existing provider community. NYSARH encourages integration of these initiatives that directs additional resource to substance use disorder treatment providers.

Long-Term Care/Human Services/Disability Services

  • Post-acute services are under-funded, putting vulnerable older adults at risk; there is a great need for increased access and funding for:
    • Long-term care
    • Skilled nursing facilities
    • Home care
    • Personal care
    • Hospice
  • Recognize that we have a staffing crisis:
    • Create a multi-year strategy to increase wages for long-term care, human service and disability direct service workers
      • Support the 2.9% cost-of-living adjustment (COLA);
    • Expand consumer-directed and decentralized service models that work best in rural communities;
  • Hospice is under-utilized in New York:
    • Healthcare providers and older adults need to be better informed of the benefits of Hospice services.
      • A public education campaign will help to enhance planning, support families and reduce suffering for people during their final year.
      • Too many people join Hospice within a few days of their death.

 Rural Health Council – The new framework for the Rural Health Council was signed into law in December 2017.  The stated purpose of this revamp was to help ensure that rural New Yorkers have a strong and active voice at the table in Albany when state bureaucrats are making decisions on programs and policies that impact the overall well-being of rural communities.

NYSARH supports this goal.  Our members are willing to serve on the Rural Health Council and to assist New York State to better support its rural residents by supporting the work of the new Rural Health Council.

 

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