An Interview with Keith Mueller, Ph.D.

by Beth Blevins

Keith MuellerKeith Mueller is the director of the Center for Rural Health Policy Analysis at the Rural Policy Research Institute (RUPRI), chair of the RUPRI Rural Health Panel, and the head of the Department of Health Management and Policy at the University of Iowa’s College of Public Health. In addition, Mueller was a member of the Advisory Panel on Medicare Education from 2004 to 2008. He is currently a member of the National Advisory Council to the Agency for Healthcare Research and Quality. Previously, Mueller was the chair of the Department of Health Services Research and Administration at the University of Nebraska Medical Center’s College of Public Health and the director of its Center for Rural Health Research. He has been involved in rural health services for more than 20 years, starting with his work in 1988 funded by (what is now) the Agency for Health Research and Quality, where he investigated patterns of uninsurance in rural Nebraska.

Mueller was the President of the National Rural Health Association from 1996 to1997, a member of the National Advisory Committee on Rural Health from 2000 to 2005, and a Faculty Fellow in Health Care Finance with the Robert Wood Johnson Foundation from 1987 to 1989.

In his spare time, Mueller enjoys leisure reading, bicycling, hiking, exploring small and medium-sized cities in Iowa, and vacationing with his wife. For more on Mueller, including a selected list of his current projects and published research, see the Rural Health Research Gateway page for Keith J. Mueller, PhD.

Since you are an expert on rural health care delivery and finance, can you share your opinion on how health care reform will affect rural communities?

I believe the ACA (Affordable Care Act) will be very beneficial to rural communities and rural people. The manner in which health insurance opportunities are created, through expansion of the Medicaid program and new opportunities for small employers, targets needs more prevalent in rural than urban areas. The public health provisions of Title IV and the workforce provisions of Title V, if fully funded, will benefit rural communities.*

Do you see any particular challenges in enacting health care reform in rural areas?

I think the biggest general challenge is that for a lot of what I’d call the systemic change initiatives in the reform legislation, such as new ways of organizing services and new ways of paying for services, our current state of knowledge is from demonstrations and pilot projects that have been done in predominantly urban areas. So the challenge we have for rural is taking those ideas and somehow making them work where you don’t have the same set of resources and the same way of doing business that you do in the urban areas. So we don’t know how things like Accountable Care Organizations would play out in rural areas; it’s one of the things we’re working on at the center now.

We don’t know how everyone will enroll through the new health insurance exchanges that will come up in 2014. We don’t know how value-based purchasing and new payment methodology will work with smaller or lower volume providers.

So there’s a lot we don’t know at this point about how to make things work better in the reform bill. That’s our biggest challenge for rural health systems. There is the immediate challenge of making sure those pieces in the legislation that everybody agrees on, like eliminating pre-existing condition clauses, benefit rural residents. That will mean making sure that everyone understands those changes, even on the individual household level, and understands how to take advantage of those changes, to purchase insurance when maybe they couldn’t purchase it before. That’s a bigger challenge sometimes in rural because it’s harder to reach people, you don’t have the congregation of people that you have in urban.

There are lots of challenges like that, but overall, the way the legislation was crafted and the way the coverage is being expanded should benefit rural, if anything, a little bit more even than it does urban, because the characteristics of the rural insurance market is more individuals and small employers, and that’s who is being targeted with some of the expansion efforts in the law.

Do you think it might be more challenging to get information out to isolated rural residents about the benefits of the health care reform package because there might be a greater suspicion of big government there than in other areas of the country?

Certainly one of the stereotypes that exists is that rural is more conservative, more anti-big government, but on an issue like this I would think it’s a little harder to tell. There’s something in public administration called “Miles Law,” which means that where you stand depends on where you sit. If you’re sitting in a rural household that is really struggling to buy or maintain health insurance coverage, and you see the possibility that you can get everyone covered including a sick child with pre-existing conditions (the legislation gets rid of pre-existing conditions for children, after 2014 no one can be denied based on that), I think a lot of households in rural America would see that and say that’s a good thing and be favorably disposed. Whereas others who are already insured or really don’t think about health insurance as something they absolutely need might be receptive to the messaging that’s going on now about the bill as big government and they’d react to that as opposed to being affected themselves by specific provisions within the bill.

Would it be more streamlined or advantageous to enroll more people in health care exchanges instead of expanding Medicaid?

One of the reasons for the expansion of Medicaid for lower income people and households is that it’s actually less expensive than paying health insurance premiums for the same population, according to how the Congressional Budget Office was scoring the legislation. The reason is that with Medicaid it’s easier to score as a single-payer system—I call it administrative price setting. There’s no negotiation with the providers and there is very limited overhead because you’re not paying for marketing, actuary capitalization, etc., that an insurer has to pay for.

The trade-off to that is if I have a Medicaid card do I have the same access to health care services as someone with a private insurance card, and the answer in some places is that maybe you don’t. Because the price setting in some areas is so low that the providers limit the number of Medicaid patients that they will absorb into their patient population. A lot of people, including members of the Senate, might have preferred doing more with private insurance, but they had spending targets that they had to stay within.

The task of making it all work will fall on the states because they’re the ones who run the Medicaid programs. They’ll have to balance the state costs of the Medicaid program with what the state needs to spend to make sure that people can find providers who will take care of them. That’s always been a balancing act for state governments, and now it will be with that many more people in the program.

There is some help in the law because the federal government will pick up 100 percent of the cost of new enrollees for the first two to three years, then they phase it down to pick up 90 percent of the cost. So hopefully this won’t be a huge burden on the states, and with the benefit of getting that much federal support, will be able to set payment levels at a reasonable rate so providers will continue to accept Medicaid payments.

If primary care and other health care services are going to expand because of health care reform, what do you think about non-MDs providing more of that care? Will it be necessary?

The best hope for making sure that services are available is to use every health care professional to the optimum of their capabilities. So, yes, that would mean using nurse practitioners and physician assistants for a lot of primary care services that you don’t need someone with the training of a physician to provide. Furthermore, you’d use health care aides to provide services you don’t need a nurse practitioner or PA to provide.

Within the statute there’s federal support for continuing to establish patient-centered medical homes. With those, you get a team of health care professionals. That includes the primary care provider but a lot of other providers like health aides and social workers. The hope is, in doing that, you have expanded the work force that you can tap into for patient care, and you’re providing the care in the most cost-effective way. So that’s one approach.

The other (approach) is different ways of getting the services to the patients. Just yesterday I toured some facilities that are using telehealth to provide emergency care services to staff intensive care units in hospitals and to help with pharmaceutical services. All that is being done out of a hub hospital in an urban area that’s reaching out to 15 small rural hospitals. If you come there as a trauma patient the trauma team at that small hospital pushes a red button on the wall and they’re immediately interacting with board-certified emergency physicians at a large facility, and those physicians can see everything that’s going on in the emergency room. That modality of service delivery will be another way of extending services to places where you really don’t have the justification to employ people full-time to do some of that care. We’re going to be studying that, but on the surface it looks like a more cost-effective way of delivering the service.

Isn’t it going to be challenging to get telemedicine out to rural areas, particularly frontier areas?

The technology is there. It’s still kind of expensive, but there are federal grant programs to help with the initial investment to extend the hardware and wiring that you need. The more critical issue we face is paying for those services when they’re delivered. Right now, in a lot of insurance plans and in Medicare, not all of those services are eligible for payment. It’s payment policy not keeping up with the changes in how care is delivered. The reform act, especially in Title III through VI of the legislation, clearly heads us in the direction of saying, instead of paying for a physical encounter, we’ll either do a global payment that covers all patient care for a period of time and the physicians can decide how to do it best, or we’ll pay for the value of the service no matter how it is delivered. We need those kinds of changes in payment policy so that the services provided by telemedicine are covered as a benefit.

You’ve worked at RUPRI for 10 years now. Can you describe the purpose of RUPRI, and what it does, in a few words?

It is to provide objective policy analysis to national policymakers—in particular, RUPRI’s core funding is from the federal government through the USDA budget—and to foster public dialog around rural health issues. Everything we do, whether it’s publishing reports and in journals, providing briefing sessions for congressional staff, or testifying before commissions and congressional committees, it is to provide analysis. Some of this is done informally, with one of us interacting directly with policy people at the federal level.

Logistically speaking, how does RUPRI work? (It’s housed at the University of Missouri-Columbia, but is a joint program of Iowa State University, the University of Missouri, and the University of Nebraska, and its core team is also based in the University of Iowa, Washington, D.C., and Texas). Would you describe it a “virtual organization”?

Yes, it is a virtual organization, but with strong programs that are anchored by collaborations with “home institutions.” We meet as a Health Panel two to four times per year, and conduct business online and through conference calls. RUPRI’s portfolio is quite diverse but the separate efforts (e.g., health, human services, entrepreneurship, telecommunications) all benefit from the core analytical capability of the RUPRI Coordinating Center. RUPRI panel leaders come together at least annually to coordinate our efforts and blend our activities into the RUPRI organization’s activities on behalf of rural people and places. As appropriate, panels and centers interact more intensively. The Rural Health Panel has initiated joint work with the Rural Human Services Panel, focused on developing and sustaining healthy rural communities.

Your undergraduate and graduate degrees are in Political Science. How did you become interested in health care finance and health care policy, specifically rural health policy? Did you grow up in a rural area?

I first moved from a research pathway in public budgeting and intergovernmental relations to one in health policy because of a long-standing interest in health issues, and opportunities to pursue those interests as political scientist in a field with very few scholars with the same background. During a health care finance fellowship I developed an interest in the rural perspective because of participating in a special national AHRQ conference to develop a research agenda in rural health services and policy research. I have never lived in a rural area, but time with my wife’s family in frontier areas in Nebraska and Wyoming has given me a deep appreciation and affection for the rural way of life. I want to be sure people who value and want to live out that lifestyle do not have to sacrifice access to high quality, timely and affordable health care services.

What sparked that “long-standing interest” in health issues?

My first job after finishing my Masters degree was working for the mayor in Milwaukee, and at that time—back in the mid-to-late 70s—the development of paramedic services was a hot topic. That was my area of responsibility for him. I really started getting into it, put it aside when I went for my PhD in Political Science, but then picked it back up again after I’d been out for awhile.

What are your current research interests?

Our research center is looking at how you make Accountable Care Organizations work in rural areas, looking at the development of health insurance exchanges, and tracking enrollment in Medicare Advantage plans. We’re also interested in evaluating new service modalities like telemedicine.

More generally, what I’m interested in as the director of the Center and in my involvement with RUPRI is what we are doing to build and sustain healthy communities. It’s not just medical care services but what we do across an array of services like transportation and economic development, and how that helps maintain the health of a population and of a community. That’s more than physical health—it’s the financial health and sustainability of the community. The (health care) reform legislation has, in Title IV, a number of grant programs and other efforts that are consistent with that more global view of maintaining the health of populations.

* For more details on Mueller’s view of ACA in a rural context, see his paper issued by RUPRI in June 2010, Patient Protection and Affordable Care Act: A Summary of Provisions Important to Rural Health Care Delivery.

Opinions expressed are those of the interviewee and do not necessarily reflect the views of the Rural Health Information Hub.

Back to: Fall 2010 Issue