Kansas Rural Health Policy Agenda

2003Kansas Rural Health Options Project

Charles T.Allred, M.D.Smoky Hill Family Practice, Salina

Keith BaileyUnited Methodist Mexican-AmericanMinistries, Garden City

Virgil BourneAtchison Hospital,Atchison

Jo Ann Doan, M.S.N., B.S.N., R.N.Fort Hays State University, Hays

John Dudte, M.P.A., MICT I/CEmergency Services Education,Wichita State University,Wichita

Kenneth L. Duensing, D.O.Kansas Osteopathic Association,Blue Rapids

Elaine JohannesResearch and Extension Office ofCommunity Health, Manhattan

Sheri Floyd, P.A.Kansas Academy of PhysicianAssistants, Ozawkie

Rick GrayArea Mental Health Center,Garden City

Leonard HernandezHolton Community Hospital, Holton

Mary Beth HermannPawnee County Health Department,Larned

John LehmanApostolic Christian Home, Sabetha

Lori LittonSt. Catherine Hospital Home CareService, Garden City

Jan MoffittMarion County Health Department,Marion

Charlotte Peake,A.R.N.P.Republic County Family Physicians,Belleville

Jodi SchmidtHays Medical Center, Hays

Lorene ValentineUniversity of Kansas Medical Center,Wichita

Kansas Rural Health Options Policy Agenda Committee

T he Kansas Rural Health Options Project (KRHOP) is a partnership among

the Office of Local and Rural Health (Kansas Department of Health and

Environment), the Kansas Hospital Association, the Kansas Medical Society,

and the Kansas Board of Emergency Medical Services. KRHOP is funded by a grant

from the federal Office of Rural Health Policy, Health Resources and Services

Administration, U.S. Department of Health and Human Services.This document was

prepared by the Kansas Health Institute. Copies are available by contacting Tom

Sipe of the Kansas Hospital Association at (785) 276-3116 or tsipe@kha-net.org.

Access to health services• Low volume and changing rural demo-

graphics require health care systems andrural communities to adapt to meet theneeds of their residents.

• The supply and availability of physicians insome rural areas is inadequate, and theentire rural primary care system is fragile.

Quality of health services• Federal quality standards do not recog-

nize the measurement and resourceissues related to quality assessment inrural areas.

• Many rural areas lack the human andfinancial resources to fully implementquality management programs.

Rural work force• The shortage of registered nurses and

allied health professionals has had a dis-proportionate impact on rural areas.

Financing of rural health services• Medicare and Medicaid prospective pay-

ment systems do not properly recog-nize the cost structure and behavior oflow-volume providers and consequentlyunderpay them.

• The burden of uncompensated care dueto uninsurance and under-insurance islarge and growing in rural areas.

Public health and emergency preparedness• Local emergency medical services sys-

tems are inadequately funded torespond to large-scale emergencies.

• Many small local health departmentspossess limited resources to deal witheither routine operations or large-scaleemergencies.

RURAL HEALTH POLICY AGENDAKansas Rural Health Options Project

All but nine of Kansas’ 105 counties are classified as rural by thefederal government. Residents of rural areas are older, sicker, andpoorer than their urban counterparts. They are more likely to be

injured or killed in an industrial accident or a highway mishap. Despitetheir need for more health services per capita than urban areas, many ruralareas experience shortages of health professionals and health care servic-es. The health care system in many rural areas plays multiple roles. It isnot merely a provider of health services, but the first or second largestemployer in the county, the meeting place for civic enterprises, and a keyvariable in economic development along with the quality of schools andlocal taxation policy. The rural health care system is not simply the urbanhealth care system in miniature. The problems caused by low service vol-umes, limited human and capital resources, travel distances betweenpatients and providers, and rural demographics are unique. The solutionsto these problems are also unique to rural areas.

The Kansas Rural Health Options Project (KRHOP), a collaborative ofthe Office of Local and Rural Health (Kansas Department of Health andEnvironment), Kansas Hospital Association, Kansas Board of EmergencyMedical Services, and Kansas Medical Society, assembled a task force ofrural health providers and educators to identify the most important ruralhealth issues in rural Kansas and to suggest reasonable solutions thatcould be implemented. The task force concentrated on five issue areas:• Access to health services• Quality of care• Health work force• Financing health services• Public health and emergency preparedness

Federal policy deeply affects rural health in Kansas. Medicare paymentpolicies and health service delivery regulations have the largest impact ofany public policies on providers of health service. Medicaid is a sharedfederal and state responsibility. Although the authority for many decisionsabout the Medicaid program resides in the statehouse, these decisionsmust be made within the framework of federal law. Federal policy influ-ences the availability of physicians in underserved areas, some of whichare rural, through a number of programs. And finally, the danger posed bybioterrorism creates new responsibilities for public health agencies andhealth care providers. Some health policies developed in Washington,D.C., have unintended consequences when implemented in WashingtonCounty, Kansas. They fail to take into consideration the size of some ruralcommunities and the unequal distribution of resources.

KEY ISSUES IN KANSAS’ RURAL HEALTH

Some of the issues identified in thisagenda are not unique to ruralareas, but they affect rural areasdisproportionately or require a dif-ferent policy solution. Solutions tothese problems are not to be foundsolely in the actions of state andfederal lawmakers. While they playan important role in addressingmany of the concerns listed here,we call on county and municipalofficials, rural communities, univer-sities and colleges, philanthropies,and rural providers themselves tojoin legislators in promoting favor-able changes in rural health.

ACCESS TO HEALTH SERVICESAccess to health services in ruralareas has three important dimen-sions: availability, affordability, andacceptability. Because of the sparsepopulation of many rural areas,some services — such as those ofmedical specialists — that mightbe available in an urban area arenot offered in rural areas. Theresimply is not enough volume with-in reasonable travel times to makesome services profitable for apotential health care professional.Consequently, local access to mostspecialty services and virtually allsub-specialty services are denied tomost rural Kansans.

The lack of health insurance cover-age or the excessive burden of costsharing for people with insurancemay cause some to forgo neededcare. Uninsured and under-insuredpeople may view health services asunaffordable, and they may notconsume services except in direemergencies. (The issue of theuninsured and under-insured is dis-cussed more fully in the section onhealth care financing.)

Services are acceptable to rural res-idents, if they are adequate to satis-fy a need or a requirement. Accept-ance is affected by knowledge,

beliefs, and the culture of care-givers and patients. When knowl-edge of the range of locally avail-able services is incomplete, resi-dents believe that the service is notavailable. In other words, theybelieve the local health care systemdoes not satisfy their needs.Incorrect assumptions about thequality of services provided byrural health care practitioners makesome rural residents seek out urbanproviders. Finally, services areacceptable only if they are cultural-ly competent. Culturally competentproviders attempt to deliver servic-es to patients in ways that recog-nize, respect, and accommodatedifferences in language, culturalvalues, concepts of time, and spiri-tual and religious beliefs.

Issue: Low Volume and ChangingRural DemographicsThe population of many rural areas— especially in western Kansas —is shrinking. On average, ruralcounties in Kansas have lost popu-lation in every census year since1930. The remaining population isolder and poorer, on average, thanurban populations in Kansas. Onearea of population growth is amongracial and ethnic minorities.Minorities in Kansas comprise 17percent of the population, up fromjust 12 percent in 1990. The pro-portion of Hispanic/Latino residentsof the state increased by 101 per-cent between 1990 and 2000. Thepopulation density of minorities insome rural counties is high. The2000 Census reports, for example,that more than half of the popula-tion of Seward County is composedof racial and ethnic minorities.

These changes in demographicsmean that health care systems inrural communities will have toadapt to meet the needs of theirresidents. Communities will needto offer more community-based and

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Access to healthservices in ruralareas has three

importantdimensions:

availability,affordability, and

acceptability.

behavioral services to allow the eld-erly to age in place. The availabilityof culturally competent health carewill have to expand to serve minori-ty residents. The smaller volume ofservices due to shrinking popula-tions will force communities todecide which services they canafford to continue offering.

Options:• Support community planning

efforts aimed at deciding the mixof health services that are neededby the community and assessingthe ability of the community tosupport and sustain those services.

• Support development of market-ing plans and tools that enablerural providers to more effectivelypromote the range and quality ofservices offered locally.

• Develop Medicare and Medicaidpayment systems and programsthat provide for community-based chronic care and preventiveservices.

Issue: Supply and Availability ofRural PhysiciansThe small number of physiciansserving rural communities and thehigh turnover among them makethe rural medical delivery systemextremely fragile. The decision ofone physician to leave a rural com-munity has a much larger impactthan the turnover of one physicianin a more densely populated area.For example, in a rural area servedby three physicians, the loss of asingle doctor would reduce theavailability of medical resources byone-third and require each remain-ing physician to increase his or herpatient load by 50 percent. Somerural communities in Kansas areserved by only one physician.

Access to certain services in ruralareas is limited by the supply ofphysicians. For example, if a gener-al surgeon is not available to pro-

vide services in the local communi-ty, no surgeries will be performeddespite the presence of a fullyequipped operating room in thelocal hospital. Because of federalprograms like the National HealthService Corps and the J-1 VisaProgram, most rural communitieshave access to primary care servic-es locally or within a short drive.Access issues typically focus onmedical specialists.

The line between primary care andsome common specialties, such asobstetrics/gynecology, pediatrics,and some internal medicine subspe-cialties, is not always clear. Forexample, a family physician maydeliver a baby or treat children.When patient volumes are low, pri-mary care physicians and specialistscompete for patients. This competi-tive environment can hamper theability of communities to recruitand retain certain specialists.

Another barrier to access in ruralareas is that some providers do notaccept Medicaid patients becausethey believe the payment rates aretoo low. Some providers do notaccept insurance assignment fromany third-party payers and requirepatients to pay in full at the time ofservice and file their insuranceclaims themselves to seek reim-bursement. This payment policy maylimit access because some patientsdo not have the resources to pay thefull amount of their medical bills.

Options:• Encourage the federal govern-

ment to maintain its investment inthe National Health ServicesCorps and continue the J-1 Visaprogram.

• Improve rural physician reim-bursement, especially forMedicare and Medicaid.

• Require all physicians and den-tists licensed in Kansas to accept

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Medicaid payments. • Maintain the state’s investment in

the Kansas Medical Student Loanprogram and the Kansas BridgingPlan.

QUALITY OF HEALTH SERVICESTwo standards of quality, one forurban providers and one for ruralproviders, do not and should notexist. All health care providersshould strive to deliver the highestquality possible consistent withtheir scope of services. Many ruralproviders, however, have difficultymeasuring and reporting the qualityof services they provide.

The current emphasis in qualitymeasurement is to assess the out-comes of care — is the person bet-ter or worse off because of the caredelivered? Outcomes are defined asunambiguous events such as a deathand are expressed as the relationshipbetween the number of people whoreceived a treatment (or who had adiseases) and the number who diedafter receiving the treatment. Forexample, the nosocomial (or hospi-tal-acquired) infection rate measuresthe ratio of hospital-acquired infec-tions to admissions at a specific hos-pital. Because of the low number ofcases in rural areas (the denomina-tor), the measurement of the qualityof outcomes and processes in ruralareas is frequently meaningless atbest and misleading at worst. Theseincorrect measures may overstate orunderstate the quality of servicesdelivered and rarely identify trueproblem areas correctly.

Issue: Inappropriate QualityStandards Licensed institutional providers suchas hospitals, nursing facilities, andhome health agencies are surveyedusing federal quality standards andguidelines developed for theMedicare and Medicaid programs.These performance standards meas-

ure the presence of an appropriatequality measurement system. For anumber of years, hospitals and otherhealth service providers have movedfrom retrospective quality assurance(QA) to continuous quality improve-ment (CQI), which emphasizes per-petual, real-time study and improve-ment of the process of health servicedelivery. Despite the improvement ofCQI over QA, the federal standardsstill emphasize QA. Retrospectivemeasurement of events and the prob-lem of small numbers make an accu-rate assessment of the quality of careprovided in rural areas difficult.

Options:• Develop quality management sys-

tems that recognize the qualitymeasurement problems of low-volume, rural providers.

• Develop federal standards thatstress quality improvement overquality assurance.

• Encourage greater interactionbetween state surveyors (inspec-tors) and rural providers toimprove surveyors understandingof rural quality issues.

Issue: Limited Quality ManagementResourcesMany rural providers lack thehuman and financial resources tofully implement quality manage-ment programs. In small ruralhealth organizations, staff membersare asked to wear multiple hats.Difficulty implementing qualitymanagement systems is often amatter of having too little time, toofew people to carry it out, too littletraining in quality improvement, ora combination of the three.Although national training pro-grams exist, generally they areexpensive, offered in distant cities,and do not focus on the needs ofrural providers. Due to the smallnumber of physicians in some ruralareas, rural physicians may beforced to use urban physicians for

peer review. Rural physicians fre-quently have a smaller menu of diag-nostics and therapies to draw on thanurban physicians. Insensitivity to thescope of medical resources availableto rural physicians can influence per-ceptions of the care they provide.

Options:• Provide training and technical

assistance on quality measurementand improvement to ruralproviders. The training should be:

• Offered at low or no cost toproviders

• Repeated routinely to reinforcelearning and accommodatestaff turnover

• Offered in sites that are easilyaccessible to rural providers

• Provided for various providertypes (for example, physicians,various hospital departments,skilled nursing facilities)

• Encourage networks of ruralproviders to work together to addressquality of care issues cooperatively.

RURAL HEALTH WORK FORCENurses and nurse aides, techniciansand technologists, physicians anddentists, and a variety of other healthprofessionals are in short supplythroughout the health care system ofKansas. Whenever there are healthcare work force shortages, ruralareas are particularly hard hit.Medicare policies that pay ruralproviders less than urban providersfor the same services inhibit the abil-ity of rural providers to compete foremployees in large regional labormarkets. Even if money for higherwages were not an issue, many ruralareas would have trouble recruitingand retaining health professionalsbecause of isolation, limited employ-ment opportunities for spouses, andurban lifestyle bias. For some healthprofessions, the current labor short-age is different than previous ones.Due to changes in the economy,demographics, and social norms, it is

expected to be widespread, long-term, and acute.

Issue: Recruitment and Retention ofNurses and Allied HealthProfessionalsIn sheer numbers, the shortage ofnurses is by far the largest healthwork force issue confronting thestate, but it is not the most acuteshortage. Hospitals are the largestemployers of most health profession-als. The Kansas Hospital Associationreported that staff nurse vacanciestotaled 358 in January 2002, for avacancy rate of 7.8 percent. In con-trast, the vacancy rate for entry-levelsocial service workers was 13.6 per-cent, but the actual number of vacan-cies was 13. Long-term care certifiednurse assistants, licensed practicalnurses, diagnostic imaging technolo-gists, respiratory therapists, laborato-ry technicians, and others are all inshort supply in rural areas. Becauseemergency medical technicians inrural areas serve largely on a volun-tary basis, the issue of EMT staffingshortages is chronic.

Options:• Develop health careers scholarship

programs targeted to rural appli-cants. (A wealth of research col-lected over 30 years indicates thathealth professionals who grew upin rural areas and who select ruralareas as their first practice site tendto remain in rural areas for the bulkof their careers.)

• Encourage state universities, col-leges, and community colleges toincrease their capacity to trainhealth professionals. The numberof instructors, classroom space, andclinical experience sites currentlylimits state capacity.

• Examine creative ways to use theeducation system to offer trainingand degrees to rural and non-tradi-tional students.

• Promote rural economic develop-ment to help provide employment

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Even if money forhigher wages werenot an issue, manyrural areas wouldhave troublerecruiting andretaining healthprofessionals.

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opportunities for spouses ofhealth services workers.

• Allow intermediate certificationduring nursing education that allowsstudent nurses to perform activitiesthey are trained to carry out.

• Limit health professional certifica-tion and licensing to occupationsthat have a clear need for stateregulation. (Creation of barriers topractice may limit the supply ofallied health professionals.)

Issue: Fewer Kansans ChoosingHealth CareersFemale workers historically havetended to predominate in the healthprofessions. In recent years, howev-er, the number of women selectinghealth careers has declined for tworeasons. The perceived attractive-ness of health professions relative toother jobs has declined, and alterna-tive opportunities for potentialhealth care workers have grown. Jobexpectations among younger work-ers have also changed. They expectbetter work conditions, more flexi-ble hours of staffing, and greaterpay than previous health profession-als. Unable to satisfy these expecta-tions in health careers, some opt forother training opportunities or leavethe health professions prematurely.Because many high school studentsare not well prepared in the biologi-cal sciences, they do not develop aninterest in health careers. Men andminorities are under-represented inthe health professions relative totheir proportion in the population. Ifthey were recruited to health careersin larger numbers, they would createa work force that better reflects thegender and ethnic/racial composi-tion of patients, in addition to help-ing alleviate the work force short-age. These factors combine to createa smaller pool of health care work-ers to replace the aging work forceand to satisfy the demand for addi-tional workers due to increases inpopulation and medical technology.

Options:• Encourage men and racial and

ethnic minorities to enter healthprofessions that traditionally havebeen filled by white women.

• Implement work place reformsthat address changing job expec-tations, such as flexible staffing,greater professional autonomy,and career ladders.

• Promote health careers and bio-science education in elementaryand secondary schools.

FINANCING RURAL HEALTHSERVICESThe low volume of services provid-ed in many rural areas creates spe-cial financial problems for ruralproviders. When the volume of serv-ices provided is below the break-even point for a practitioner or facil-ity, it is unprofitable to continue tooffer the services. Raising the pricesof services is not an effective alter-native because few patients pay theactual prices set by providers. Tocontinue to offer an unprofitableservice requires a provider to cross-subsidize the service with a prof-itable service, obtain non-operatingincome from gifts or local taxes oruse accumulated equity until it isexhausted.

Low volumes also produce higheraverage costs. The cost of goods andservices is comprised of variablecosts and fixed costs. For the mostpart, fixed costs do not change withthe number of goods and servicesproduced and are distributed evenlyover the number of units produced.When fewer units are produced,fixed costs per unit are higher. Thehigher contribution of fixed costs atlow volumes means that the cost ofmany services produced in ruralareas are higher than those producedat higher volumes. Rural providersattempt to deal with this situationwith cost-saving strategies such asoffering lower wages and benefits,

Raising the prices ofservices to break

even is not aneffective alternative

because few patientspay the actual prices

set by providers.

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streamlining staffing, and closingunprofitable services.

Issue: Government PaymentSystems are Inappropriate forLow-volume ProvidersBeginning in 1984 with Medicarepayments for inpatient hospitalservices and expanding over timeto Medicaid and a variety of otherhealth care providers, governmentshave implemented prospective pay-ment systems. Under prospectivepayment, a fixed payment rate isset, based upon the average cost atan average facility. If a providercan deliver the service at less costthan the fixed payment, theprovider can keep the difference. Ifit costs a provider more to deliverthe service than the payment, how-ever, the provider must absorb theloss. Intended to create incentivesfor provider cost reduction,prospective payment works well intheory at large volumes where prof-itable and unprofitable services bal-ance each other out. Because manylow-volume providers have vol-umes whose costs are above pay-ment rates, they lose money onmost services. When outliers occur— patients who require more careor care at greater cost — lossesgrow even deeper. In addition,Medicare adjusts its payment ratesgeographically, paying rural facili-ties and individual practitionersless than it pays their urban peers.

Option:• Redesign Medicare and Medicaid

payment systems to properly rec-ognize the cost structure andbehavior of rural providers.

Issue: Uncompensated Care“Uncompensated care” is servicedelivered for which a providerreceives no compensation. Inaccounting terms, it is the sum ofcharity care and bad debts,although many rural providers do

not even track uncompensated care.Hospitals that received Hill-Burtonconstruction grants and NationalHealth Service Corps clinicians arerequired by federal law to treatpatients without regard to theirability to pay. The mission state-ments of many hospitals promotethe provision of charity care. Manyrural providers also follow thisrule, but some do not acceptpatients who are uninsured or can-not afford to pay for services out-of-pocket. Some do not acceptMedicaid patients because theybelieve the payment rate is too low.Although it has not yet become aproblem in Kansas, national reportsdocument that physicians in otherstates have begun to opt out of theMedicare program because of lowpayment rates. When someproviders restrict services topatients on the ability to pay or thesource of payment, these patientstend to cluster disproportionately inpractices and facilities that doaccept them.

Most uncompensated care is deliv-ered to people who do not havepublic or private health insurance.Rural populations tend to havelower rates of insurance than urbanareas. Many small employers, whoare the major employers in ruralareas, cannot afford the cost ofhealth insurance and do not offer itto their employees. Rural areas alsohave a higher proportion of self-employed individuals who cannotafford the cost of premiums in theindividual insurance market.Another source of uncompensatedcare is “under-insurance,” whichoccurs when patients are unable topay their cost-sharing obligation(deductible and co-insurance).Services for patients without healthinsurance and who meet provider-determined criteria for indigenceare considered charity care. Carefor a patient who is under-insured

or for a self-pay patient who cannotafford to pay the entire bill is con-sidered a bad debt.

Payments by Medicare andMedicaid to most rural providersare less than the amount theproviders charge for their services.The difference between the amountpaid and the amount charged iscalled the “contractual allowance.”Because Medicare and Medicaidpayments do not keep pace withmedical inflation and changes inthe health care product due to tech-nology and patient demand, theratio of contractual allowances tocharges grows larger every year.

Options:• Improve systems to enroll people

who are eligible for public healthinsurance programs, but who havenot applied for them.

• Improve access to the small groupinsurance market:

• Low-premium expansions ofpublic insurance programs tocover the working poor

• Insurance risk-pooling forsmall employers

• Encourage employers who hireforeign workers to help assureadequate health care for them.

• Eliminate unnecessary complexityand intentional delays in insurerpayment systems to speed pay-ments to rural providers andreduce their investment inaccounts receivable.

• Provide tax incentives to smallemployers who offer health insur-ance to their employees.

PUBLIC HEALTH AND EMERGENCY PREPAREDNESSThe threat of bioterrorism thatemerged after the events ofSeptember 11, 2001, placed newemphasis on public health and thesystems of care that support emer-gency preparedness. After decadesof neglect, federal money is now

being made available to improvepublic health infrastructure so thatlocal health departments can respondto a biological or chemical attack. Asone federal official said recently, “Ittakes a system that is competent tohandle routine public health situa-tions to handle the emergencies.”

The rural emergency medical serv-ice (EMS) system is extremelyfragile. It relies largely on volun-teers to operate it. Training volun-teers to assure their ability torespond in emergencies is a con-stant challenge, as is staff turnoverand scheduling. Local EMS sys-tems are owned and operated by avariety of public and private organ-izations throughout the state. Theequipment and supplies used varywidely. Although in Kansas, EMSsystems are regulated and support-ed by the Board of EmergencyMedical Services, at the federallevel, EMS has no “policy home.”Federal concern for EMS floatsbetween the Department of Healthand Human Services and theDepartment of Transportation. In thebillions of dollars allocated to thefight against bioterrorism, not a sin-gle cent has been earmarked espe-cially for EMS development, an oddomission given the importance ofmedical transportation and pre-hos-pital treatment in an emergency.

Issue: Under funding of EMS for Emergency PreparednessRural EMS systems are rarely prof-itable. Like firefighters, EMS pro-fessionals largely stand by, waitinguntil they are called upon to providecritical life-saving services inunforeseen, sometimes dangerous,moments. The number of calls theyreceive in any given year are small,especially compared to urbanproviders. Although much of thestandby costs of EMS are reducedby the use of volunteers, the cost ofambulances and the equipment used

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in them represent a substantial capi-tal investment. Only a fraction ofthe true cost of providing EMS serv-ices in rural areas is ever recovered.

While bioterrorism is the primarythreat for which the health care sys-tems of Kansas are preparing torespond, it is not the only threat forwhich emergency preparedness iswarranted. Weather emergencies,train, plane, and multiple carwrecks, and industrial accidents aresome of the emergencies that willrequire pre-hospital treatment andmedical transportation. To date,EMS systems have not been wellintegrated into emergency prepared-ness planning at the local level.

Options:• Promote bioterrorism prepared-

ness funding for EMS systemimprovements.

• Concentrate federal EMS policy-making in a single agency, prefer-ably the Department of Healthand Human Services.

• Encourage organizations andagencies that deal with emergencypreparedness planning to integrateEMS more fully into their efforts.

• Encourage state universities, col-leges, and community colleges tomaintain their EMS professionaltraining programs.

Issue: Limited Public HealthCapacity in Small Local HealthDepartmentsThere are 99 local health depart-ments in Kansas, almost one foreach county. Public health is one ofthe basic services of local govern-ment. Like the sheriff or the firedepartment, public health officialshelp protect the public and ensuretheir safety. While the sheriff andthe fire department deal withthreats of violence and fire, publichealth professionals deal with low-ering the risk of communicable andenvironmental disease. Because

public health is not well understood— and because when it works well,it is invisible to the public — it hasnot received much attention inrecent years. Many small localhealth departments lack the neededinfrastructure to do their jobs effec-tively. The public health infrastruc-ture means the capacity and com-petence of the work force, informa-tion and data systems, and localhealth department organizationalcapacity, as measured by perform-ance standards.

Options:• Encourage development of coop-

erative networks among localhealth departments to share serv-ices and leverage scarceresources.

• Involve county commissioners inpublic health planning to a greaterdegree.

• Build incentives into state fundingof local health departments thatencourage greater cooperationand regionalization of services.

• Encourage and assist publichealth workers to obtain addition-al training in public health.

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The threat ofbioterrorism thatemerged after the events ofSeptember 11,2001, placed newemphasis on publichealth and thesystems of care thatsupport emergencypreparedness.

Produced by

Kansas Health Institute212 S.W. Eighth Avenue

Suite 300

Topeka, KS 66603-3936

for

Kansas Rural HealthOptions Project215 S.E. Eighth Avenue

P.O. Box 2308

Topeka, KS 66603-2308

KANSAS HEALTH INSTITUTE