Federal employees health program experiences lack of competition in some areas, raising cost concerns for exchange plans

The Affordable Care Act calls for creation of health insurance exchanges designed to provide private health insurance plan choices. The Federal Employees Health Benefits Program is a national model that to some extent resembles the planned exchanges. Both offer plans at the state level but are also overseen by the federal government. We examined the availability of plans and enrollment levels in the Federal Employees Health Benefits Program throughout the United States in 2010. We found that although plans were widely available, enrollment was concentrated in plans owned by just a few organizations, typically Blue Cross/Blue Shield plans. Enrollment was more concentrated in rural areas, which may reflect historical patterns of enrollment or lack of provider networks. Average biweekly premiums for an individual were lowest ($58.48) in counties where competition was extremely high, rising to $65.13 where competition was extremely low. To make certain that coverage sold through exchanges is affordable, policy makers may need to pay attention to areas where there is little plan competition and take steps through risk-adjustment policies or other measures to narrow differences in premiums and out-of-pocket expenses for consumers.     

Improving Access to Capital for Health Care Infrastructure: The Experience of the Southern Rural Access Program's Revolving Loan Fund

ABSTRACT: Lack of access to affordable capital is a formidable barrier that compromises rural health care infrastructure development in poor rural areas. Commercial lending institutions are often limited in their ability to respond to those needs due to traditional lending criteria: creditworthiness, equity, management ability, experiences, and cash flow or profits. In the Southern Rural Access
Program, a development model more frequently used in other sectors has been successfully applied to health care to help clear these hurdles. This paper describes the 5 operational loan funds in Arkansas, Louisiana, Mississippi, South Carolina, and West Virginia receiving support from the Southern Rural Access Program. Two models of loan funds have evolved: those led by health agencies and those led by community development finance institutions whose mission is rural economic development. This paper outlines major distinctive features of these 2 approaches and describes major implementation challenges these loan funds fce. Key accomplishments are highlighted, including the ability to leverage additional resources from state, federal, philanthropic, and private sources through these funds. These loan fund programs provide models for other states interested in improving access to capital to help build the rural health care infrastructure while making health care more economically viable through integration with other community development initiatives.     

Capacity building to improve women's health in rural China

The Women's Reproductive Health and Development Program (WRDHP) is an ambitious attempt to operationalize two important tenets of health development thinking within a rural reproductive health context. First, it is important for communities to participate in decisions about the services and programs that affect them. Secondly, the complex nature of healthcare is best addressed by intervention processes which call for a multi-functional approach to planning and coordination. In both planning and intervention approach, the WRHDP recognizes the social, cultural and economic realities that affect women's efforts to secure the health and well-being of themselves and their families. The focus of the WRHDP is on capacity-building within a rural reproductive health environment, in this case Yunnan Province in rural China. Rather than using international donor funding to provide a specific intervention, the WRDHP used Ford Foundation funding as a lever to encourage community investment in environmental resources that affect health, to improve the technical skills of individuals within the existing health bureaucracies, and to promote structural changes within existing health and development bureaucracies to support interagency collaboration and community empowerment within the region's health and development agencies. This article describes how the WRHDP created new methods for provincial and local agencies to overcome obstacles and work with one another to improve women's health. It also describes the processes used in the rural areas of Chengjiang and Luliang counties to assess local conditions and needs, and the supported and expanded local efforts in improving woman's reproductive and family health that resulted from the processes.     

Lessons Learned in Phase I of the Southern Rural Access Program

ABSTRACT: The Robert Wood Johnson Foundation's Southern Rural Access Program has been an important investment of philanthropic funds to augment resources and improve health care access in underserved rural communities. The program's first phase has taught important lessons about building capacity in rural health care. This article uses a variety of data to document the program's major accomplishments and most significant challenges to date. The program's revolving loan fund efforts are promising. The program has also played a catalytic role in stimulating rural health network development in the South and has helped stimulate partnerships with Southern philanthropies and multiple local, state, and federal agencies. Challenges have included the broad geographic and programmatic focus of the initiative as well as changing and often difficult state policy environments. Additional challenges include maintaining interagency coordination over time and managing staff and lead agency turnover. Overall, the experience suggests that a concentrated regional approach has merit .     

Strengthening primary health care: building the capacity of rural communities to access health funding

ABSTRACT: Present health funding models can place onerous pressures on rural health services. Staff may lack the time, resources, access to data, and the expertise needed to complete complex and lengthy funding submissions. This present study describes an innovative capacity-building approach to working with Victorian rural communities seeking to access health care funding through the Regional Health Services Program. This approach used several strategies: engaging stakeholders in targeted rural communities, developing an information kit and running a workshop on preparing submissions to the Regional Health Services Program, facilitating community consultations, and providing ongoing support with submissions. Six rural communities were supported in this way. Four have been funded to date, with a combined annual recurrent budget for new primary health care services of over $2.5 million. Each community has developed a service delivery model that meets the particular needs of their local area. This capacity-building approach is both effective and replicable to other health funding opportunities.     

Impact of federal primary health care policy in rural areas: empirical evidence from the literature.

This review examines the equity, efficiency and effectiveness of federal rural primary care policy as documented by the existing literature. The focus is on the Community Health Center and National Health Service Corps programs which have constituted the major components of the policy. The literature relating to the policy is limited in the number of studies available and in the quality of the research. The available evidence indicates that the policy is associated with an improvement in the distribution of health resources between rural and urban areas,and among rural areas.There is also partial evidence that the policy has been cost-efficient. For federally subsidized practices,the cost of delivering a similar quality of health care is shown to be up to 50 percent less in rural than in urban areas. Rural private practitioners, though, may be more cost-efficient than federally subsidized rural practitioners, at least under certain conditions which have yet to be fully delineated. Program effectiveness is the least well documented, but the literature does suggest that the policy has had a positive effect on the health status of rural populations. Substantially more research on the efficiency, and particular the effectiveness, of federal rural primary care policy is required for the development of a rational basis for the policy.     

Interorganizational Network Changes Among Health Organizations in the Brazos Valley, Texas

Community health development is a process by which a community identifies factors influencing population health, assesses available resources to build the capacity to plan and take action, and implement interventions to address identified needs. At its core, community health development targets structural change and infrastructure development to facilitate more efficient and effective health service delivery systems and environmental changes to support improvements in community health. One indicator of structural change and common measure of community capacity is the relationships among the network of organizations that comprise that system. The Brazos Valley has employed a community health development approach to population health improvement in partnership with the Center for Community Health Development. Changes in interorganizational networks illustrate progress in the Brazos Valley. Contextual factors provide some insight into how the process has unfolded.     

Environmental health services in primary care centers

Primary Health care centers supported by the Public Health Service through the Community Health Center and Migrant Health Centers programs are now required to provide environmental hazards directly related to clinical findings, but correcting community and occupational environmental problems may be pursued through appropriate agencies. State and local health departments will play key roles in the program in providing professional expertise in environmental health, assisting patients in taking corrective action, and assisting in the coordination with state, local, federal and voluntary agencies. Some primary care centers in areas of great need and limited resources will have their own environmental health professionals, but most will depend on local health departments for this specialty.     

Expanding home health services: evaluation of the federal grant program

The federal Home Health Grant Program was initiated in 1976 and is intended to increase the provision of home health services by means of grants for the expansion of existing home health agencies and the development of new ones. The evaluation of the grant program is summarized in this article, emphasizing the visit increases generated by grantees and the factors associated with successful grantee performance. Although the grantees were generally successful in increasing visits, grantee performance varied considerably in terms of certain agency and locational characteristics. In particular, Visiting Nurse Association agencies demonstrated considerably better performance than other types of agencies.     

Getting what you pay for: public health spending and the performance of essential public health services.

Governmental spending in public health varies widely across communities, raising questions about how these differences may affect the availability of essential services and infrastructure. This study used data from local public health systems that participated in the National Public Health Performance Standards Program pilot tests between 1999 and 2001 to examine the association between public health spending and the performance of essential public health services. Results indicated that performance varies significantly with both local and federal spending levels, even after controlling for other system and community characteristics. Some public health services appear more sensitive to these expenditures than others, and all services appear more sensitive to local spending than to state or federal spending. These findings can assist public health decision makers in identifying public health financing priorities during periods of change in the resources available to support local public health infrastructure.     

Breaking rural health care paradigms leads to collaboration. Interview by Donald E. Johnson

Strategic planning in a rural community is a challenge. Trying to predict the impact of federal health care reforms while undertaking a 30 million dollar capital construction campaign to consolidate two deteriorating hospitals into one new medical center could have been a nightmare. Health Care Strategic Management publisher Donald E.L. Johnson and Eastern New Mexico Medical Center president and chief executive officer James K. Knoble discuss the challenges of federal health care reforms and rural health care administration, and explore potential opportunities for collaboration and integration.     

Are rural health professionals also social entrepreneurs?

Social entrepreneurs formally or informally generate community associations and networking that produces social outcomes. Social entrepreneurship is a relatively new and poorly understood concept. Policy promotes generating community activity, particularly in rural areas, for health and social benefits and ‘community resilience’. Rural health professionals might be well placed to generate community activity due to their status and networks. This exploratory study, conducted in rural Tasmania and the Highlands and Islands of Scotland considered whether rural health professionals act as social entrepreneurs. We investigated activities generated and processes of production. Thirty-eight interviews were conducted with general practitioners, community nurses, primary healthcare managers and allied health professionals living and working rurally. Interviewees were self-selecting responders to an invitation for rural health professionals who were ‘formally or informally generating community associations or networking that produced social outcomes’. We found that rural health professionals initiated many community activities with social outcomes, most related to health. Their identification of opportunities related to knowledge of health needs and examples of initiatives seen elsewhere. Health professionals described ready access to useful people and financial resources. In building activities, health professionals could simultaneously utilise skills and knowledge from professional, community member and personal dimensions. Outcomes included social and health benefits, personal ‘buzz’ and community capacity. Health professionals' actions could be described as social entrepreneurship: identifying opportunities, utilising resources and making ‘deals’. They also align with community development. Health professionals use contextual knowledge to envisage and grow activities, indicating that, as social entrepreneurs, they do not explicitly choose a social mission, rather they act within their known world-view. Policymakers could consider ways to engage rural health professionals as social entrepreneurs, in helping to produce resilient communities.     

Developing an Evaluation Plan for School Health Programs in Nebraska

ABSTRACT: This article describes a unique plan for comprehensive evaluation of school health programs. With property tax caps threatening Nebraska's school health programs, the Nebraska Dept. of Health and Human Services initiated an evaluation plan to answer the question, “What is the value of school health?” The plan used the “Targeting Outcomes of Program” (TOP) framework to measure impact indicators of a comprehensive school health program. To customize the plan for Nebraska schools, community input was sought from stakeholders identified from a small rural school district. Following a series of focus group meetings, the final evaluation plan was developed and implemented as a statewide evaluation of comprehensive school health services. The resulting plan addressed several deficiencies previously identified in the literature by including community input, attention to multiple roles, and measurable outcomes documenting effectiveness, or value.     

Reflections from The Robert Wood Johnson Foundation on The Program to Strengthen Primary Care Health Centers

Given the modest amount of resources provided by the Foundation through The Program to Strengthen Primary Care Health Centers, the grantees undertook a high level of activity. Perhaps centers were aided by the momentum and focus of the Program in addition to financial resources. Such grants seem to move longer-range projects onto the daily agendas of managers. It might be worthwhile to convert some portion of federal community health center funding to support financial and managerial innovations. Generally, positive evaluation findings should encourage centers to explore some of the demonstrated initiatives. Evolution and innovation are considered key to the survival of primary care health centers.     

Fifteen years of community organization for health in Panama: an assessment of current progress and problems

Since the late 1970s the WHO and other international agencies have placed much emphasis on strategies of community organization in order to improve preventive health services and facilities in rural areas. Many countries have recently set out to reform their rural health systems by means of a community-based approach. Panama's 15 years of experience in 'community health' provide insight into the constraints to program continuity at the national level and to maintenance of participatory mechanisms (health committees) at the village level. This paper focuses on the present status of the Community Health Program and level of activity of the health committees. This study is based on in-depth interviewing of key program participants at three contexts: central ministry, district/regional health institutions and rural communities. It sought to discover how interactions among and within these contexts affected program services and community participation. Inconsistent outcomes are evident. In some areas the Community Health Program thrives and the health committees are active, while in most areas the program functions at a minimal level and most health committees are inactive. Several factors are identified which affect a 'successful' or 'unsuccessful' program environment. These include: degree of support from medical directors of district and regional health centers, existence of 'federations of health committees', the extent of political interference, the presence of a functional 'technical health team' and degree of community confidence in health committee officers.     

Wisdom from the drought: recommendations from a consultative conference

OBJECTIVE: Drought is a serious and recurring problem for rural and remote Australia. This paper reports the proceedings of a consultative conference concerning the mental health effects of drought held at the Centre for Rural and Remote Mental Health, Orange, in December 2003. The conference objective was to record the collective experience of government and non-government agencies dealing with the effects of drought in rural areas and to collate information for the development of a mental health strategy for future drought. DESIGN: Participants were recruited in consultation with rural mental health organisations. Questions about mental health service strategies to minimise and respond to the mental health impact of the drought were posed to participants. Qualitative data were collected using a Nominal Group Technique. SETTING: The Centre for Rural and Remote Mental Health, Bloomfield Hospital, Orange, New South Wales. PARTICIPANTS: Twenty-three professionals participated, including representatives from New South Wales Health, Mental Health, and Agriculture; the Department of Community Services, and Rural Financial Counsellors. MAIN OUTCOME MEASURE: Qualitative analysis of participant responses. RESULTS: Three general strategies emerged as the most beneficial in minimising adverse mental health outcomes in times of drought: community-building and education about the physical, financial and mental health effects of drought; co-operation between and co-ordination of agencies in delivering mental health and other drought support; and continuity and planning of improved mental health services. CONCLUSIONS: Drought has a serious effect on the mental health of communities. It is important to plan a response beyond the end of the drought, bringing together different government and non-government agencies to build community capacity to address common mental health needs.     

New partnership for health? Business groups on health and health systems agencies.

The experience of the Central Massachusetts Health Systems Agency (CMHSA) and the Central Massachusetts Business Group on Health (CMBGH) demonstrates the feasibility of cooperation between HSAs and BGHs. Objectives and strategies of the two groups in carrying out community health planning and working for health systems change are compared. Nearly two decades of government-sponsored community health planning programs, first through comprehensive health planning agencies and then through HSAs, have had less impact than many had anticipated because neither the technical nor political basis for such planning was sufficiently established. The CMHSA experience is typical, although it is credited with developing a hospital systems plan that is based on sound planning methods and statistical data. It is in the implementation of plans that the CMHSA has made slow progress, reflecting its inadequate community power base. The CMBGH, 1 of more than 90 groups that have developed recently across the country to attack high health care costs, was formed in 1981 by business leaders to address these rising costs. The principal strategy adopted by the CMBGH involves fostering a competitive health care market by creating a critical number of competing health plans. The providers in each plan will then have incentives to provide effective care in an efficient manner to keep the premium competitive and attract enrollees. Cooperation between the CMBGH and CMHSA is based on each organization''s emphasizing its strengths. The CMHSA''s data base and analyses have been the primary resources used by the CMBGH to identify problems. Each organization has developed its own set of goals and objectives, while keeping in mind those of the other organization.(ABSTRACT TRUNCATED AT 250 WORDS)     

National environmental public health tracking program: bridging the information gap

In January 2001 the Pew Environmental Health Commission called for the creation of a coordinated public health system to prevent disease in the United States by tracking and combating environmental health threats. In response, the Centers for Disease Control and Prevention initiated the Environmental Public Health Tracking (EPHT) Program to integrate three distinct components of hazard monitoring and exposure and health effects surveillance into a cohesive tracking network. Uniform and acceptable data standards, easily understood case definitions, and improved communication between health and environmental agencies are just a few of the challenges that must be addressed for this network to be effective. The nascent EPHT program is attempting to respond to these challenges by drawing on a wide range of expertise from federal agencies, state health and environmental agencies, nongovernmental organizations, and the program's academic Centers of Excellence. In this mini-monograph, we present innovative strategies and methods that are being applied to the broad scope of important and complex environmental public health problems by developing EPHT programs. The data resulting from this program can be used to identify areas and populations most likely to be affected by environmental contamination and to provide important information on the health and environmental status of communities. EPHT will develop valuable data on possible associations between the environment and the risk of noninfectious health effects. These data can be used to reduce the burden of adverse health effects on the American public.