RHC TA Conference Call Transcript

CAPITOL ASSOCIATES

Moderator: Bill Finerfrock
April 02, 2008
1:00 p.m. CT

Operator: Good day everyone and welcome to today’s Rural Health Clinic technical assistance call on proposed changes for the shortage designation process. Today’s call is being recorded.

At this time, I would like to turn the call over to Mr. Bill Finerfrock. Please go ahead, sir.

Bill Finerfrock: Thank you, operator. I want to welcome everyone to today’s call on proposed changes to the shortage area designation process. This call was originally scheduled for March 11th, but was postponed until today.

My name is Bill Finerfrock, and I’m the executive director of the National Association of Rural Health Clinics, and I’ll be moderating today’s call. Our presenter is Captain Andy Jordan, who is the chief of the Federal Shortage Designation Branch at the Health Resources and Services Administration. Andy will address the recently released proposed rule, and recommend sweeping changes in the way shortage area designations, both medically underserved areas and health professional shortage areas, are designated. And then we’ll take questions at the conclusion of her formal presentation.

Today’s program is scheduled for an hour. We will have Andy’s presentation, and then, as I said, questions following. This call is part of a series sponsored by the Health Resources and Services Administration Federal Office of Rural Health Policy in conjunction with the National Association of Rural Health Clinics. The purpose is to provide rural health clinic staff with valuable assistance in RHC-specific information.

Today’s call is the 23rd in the series, which began late in 2004. As you all know, there is no charge to participate in this program, and we encourage you to refer others who might benefit from this call to sign up to receive announcements regarding the call date’s topics and presentations. If you go to the Web site www.ruralhealth.hrsa.gov/rhc, you can get instructions on how to sign up to participate in this series.

During the question and discussion phase of the call, we do ask that you provide your name and the location you’re calling from prior to asking your question. In the future, if you have questions, you can e-mail those to info@narhc.org and put Rural Health Clinic Teleconference Question/Topic in the subject line. I want to remind callers to – you can follow along. We’ve provided you with a copy of the Powerpoint presentation that Andy uses, and was sent to you via e-mail.

With that having been said, I would like to welcome Captain Andy Jordan, who’s going to talk to us about the proposed changes to the shortage area designation process. Go ahead, Andy.

Andy Jordan: Thank you, Bill. Sorry that we had to put off the call, but glad to be able to get back. And I’m trying to catch up a little bit.

I’m going to go kind of quickly through the slides that were prepared and distributed, I guess, and are available for you because I don’t want to read them all. You can look at them. And some of them are really visual anyway, so talking about them is not very useful by reading to do over the phone.

Briefly, we wanted to give a little bit of background for people who aren’t as familiar with this topic, and some others might be. There are currently two designation methods, as Bill mentioned. There’s the health professional shortage area, which came out of the National Health Service Crps program, and the medically underserved area and populations program, which really is primarily linked to the Community Health Center program. They both came out of those legislative histories and started in the late ‘70s.

Since then, a lot of things have been added to those two methods, including the Rural Health Clinic certification eligibility process. then you’ve got the Medicare incentive payment and a number of other things. Obviously, the one you’re most interested in is the Rural Health Clinic issue.

So, historically, there have been two methods. They’re similar but different. They came from different places. They were meeting different needs. They’re now used by lots of people.

And over the years, a number of criticisms have developed, one being why do we have two instead of just one. A lot of them are the same. There is probably an 80 percent overlap. Why do I have to do two different kinds of designations when the results are very similar.

In addition, major issues were raised about the failure to include nurse practitioners, physician’s assistants, and nurse midwives in the counts because they clearly are primary care providers. And that’s been a consistent criticism of GAO and some other places. There is also a sense that the methodologies that were developed in the ‘70s really don’t reflect a lot of high-need indicators that may be more appropriate now. And there are issues related to access that aren’t captured in the current methods.

MUAs are not required to be updated, and there are a number of them that are at least 20 years old. HPSAs are updated on a regular basis, so that’s not an issue with them. But there is a concern that some of the MUAs are very, very out of date. You all have some familiarity with that because you have to meet a – at least new ones have to meet the three-year update and have had to go through that process. And updating MUAs with current criteria would be extremely difficult because they’re very outdated.

And we continue to have questions raised about the issue, what people call the “yo-yo” effect – if you look at the bottom of slide four – that if I get resources into an area, be they people, be they dollars, or whatever – because I’m in a designated area, then the resources are there. Somebody looks at the area and says, well, those resources are there so it is no longer designated, so then I lose eligibility. They pull them out, and I fall back down again. I need the resources. And that’s a problem.

So, one of the ways that’s been built into this one is they try to take that into account. You can look in areas with and then without resources and see what the differences are. So, all of those things brought an interest in developing a new method.

Those of you that have been around for a while may know that in 1998, they started this process of developing one. They put it out for comment as this one is out now, and basically got blown up to a large extent because of the rural impact, at least as people looked at it. It seemed to have a pretty devastating impact on rural areas in particular. It was not very balanced, and some other issues were raised. So, they basically threw that out and started over.

And what you see now is a result of that starting-over process, trying to do a better job, still trying to be relatively simple, to have one method, to try to be a little bit more accurate and respond to some of the other criticisms. So they really look for a scientific basis for the various factors and how they are used. Look at slide six. They really use those guiding principles to focus the work, if we’re using an indicator, why we’re using that, and is it being used in a way that we can demonstrate as related to it being a barrier to access and those kinds of things, and minimizing the disruption on the existing safety net.

I’m not going to go into the methodology in any great detail. You can read it if you want. If you have trouble sleeping, it might be a really good idea to read it. But briefly, to go through the next three or four slides, the concept basically is we’re looking at how to measure access. And one measure of getting an access is how easy or hard is it for people to use services as measured by visits. And we really use visits as a foundation for this as a measure of access.

Those of us who have good insurance, when we have a visit to our doctor rate and we don’t have a barrier doing so. Well may or may not be true all the time. But in general, we are able to have access when we want it, when we need it. And then there are other populations who, for a variety of reasons, don’t have access, so they’re lower – their rates of utilization are lower. And their needs may in fact be higher because of that.

That’s the basic principle behind it. So it really – it starts looking at a population. And while the current method looks at how many people are there in the area and then how many providers are there, this one has a refinement to that by saying how many people and what age and gender are they, because it makes a difference in terms of utilization what age and gender you are.

So it modifies the population based on that distribution, in that it has a different result that more accurately reflects what actual utilization you might expect, and therefore what demand does that community have. It then looks at a number of need factors to say: these are things are barriers to access. If people have these characteristics – those areas have these characteristics – they’re going to have greater need. They’d have greater health problems. They’d have lower access. And so we need to take that into account.

And ultimately – I guess you get all the way through to slide 13, looking at the actual factors that were used to adjust the need/demand above what you would expect because they really need more. And they need more because of the various factors: for example their very high-poverty rate. Low density was one factor that was specifically put in for the rural health issue .
If you look at slide 13, you can see what those factors are that were included in the model. So it basically takes a population adjustment for age and gender distribution, looks at the number of providers that are there, and comes out with a sort of an initial ratio. Then it modifies that ratio based on those need characteristics.

Slide 14 gives a brief summary, and it’s detailed more in the actual publication. You could imagine they looked at probably 100 or so factors in the process. The ones that they came down to were these nine. A lot of it had to do with where you could actually get data at a reasonable level and, you know, reasonably consistently and reasonably stable, to be able to use something in a model like this. And a lot of factors overlap or have very similar effects, and they were able to use one as a proxy for another.

So that’s the basic model. And the next few slides show a couple of examples of how it works in a particular community, how the age and gender distribution can increase the demand, and then how need factors could actually make a difference in a particular community. So I’m not going to go through that in a lot of detail.

It gets kind of like a “black box” after a while. You’re going to have to really focus on the pieces when you’re looking at some of those slides. But anybody who likes to do that, you can certainly do that.

On slide 19, we start talking about the impact, because one of the things that they did this time around that they did not do the first time, was really do an extensive impact testing. What is going to happen when we do this, when we look at current designations and where do they go, when we look at safety net providers and what happens to the areas that they’re in, what’s going to happen to them when this is done?

And the next few slides kind of show different ways of looking at that. The one with the bull’s eye, number 20, the outside circle is sort of the current number of designations. That’s a combined MUA and HPSA number at that time, with the outside circle. The smaller inside circle was if you redid all the calculations in the current methods now, you’d only get 68 percent of those areas sticking around.

So it tells us we’re a little concerned, as redoing the current method would maybe not be very effective, and we’d lose a lot of people and places. The end – the circle that’s lighter around that, which ends up – which says 91 percent – that by the end of going through several stages of testing in this, we estimate that approximately 91 percent of the existing designations will remain. That’s an estimate, and it stays on national testing. And we suspect that local data will probably change that, but that’s a rough cut.

The next slide, 21, shows the difference between metropolitan and non-metropolitan frontier areas. Not surprisingly, the metropolitan areas are the hardest to do from a national data standpoint because the national data become much further from reality when you’re dealing with very complex, large urban areas than they do in non-metropolitan and frontier areas. Those – you can look at those columns in there. They’re almost identical from the current to the final testing. Same thing with 22, which is population instead of numbers of designations.

Slide 23 looks at the impact on actual safety net providers. This was at the time it was done, which was 1999 or 2000. So in some ways, it is a different universe that was around then than is around today. But – and looking at what happened to health centers, areas that they’re located in from the current – the current level and the various different cuts of the new method, National Health Service Corps sites, and then Rural Health Clinics. And you got -it’s a confusing and complex slide- and you got metropolitan, non-metropolitan and frontier in it as well.

Well, it does show, in general, for rural and frontier areas, not much change. You don’t see very big drips in those columns over time, they’re pretty stable if you look at the base and what happens at the end of the new method. And because the rural health impact was so huge the first time, you know, they did a lot of looking at that when they considered this particular method when they tested it.

The two-tiered approach I talked about before on slide 24 was built into this process so that you can then look at areas with all the resources in it. And then you can back out the resources that are in there because of the designation.

And the next slide, 25, kind of shows you what happens when you do that. You can back out health center providers. You could back out national service corps places, and back – backing out others. And that allows you to make a difference between places that have a level of service now.

And you don’t want to take away a designation if it drops below the line when the existing resources are counted, because if you did, they would drop below the line and lose those resources. But maybe you not want to add more there because there are other places that qualify, even though they have all the resources you’ve already got there. So it really becomes a more precise tool in terms of targeting resources.

In terms of the overall impact – again, this is information that really was 2000- 2001 – slide 26 summarizes roughly the areas of the country – I guess 27 really talks about some states that did testing. The northeastern part of the country does a little less well than some other parts of the country. But overall, it looks like most states will retain over 80 percent of the currently designated areas– on national testing without getting any local data. The northeast is the area that would appear to be the hardest affected. The four states tested it themselves with their own data, seemed to be pretty comfortable.

The slide with the map– I apologize, the slide’s hard to read. I don’t have a much better one. And if you blow it up – I’m not sure how useful it is, but it gives a rough visual look at things.

The way the process would work – and it’s important to understand that there are several levels to this. You work your way through all of the levels before you find out – before anybody is lost or dropped out of the system.

The first thing that would happen is that we will do kind of what we did with testing, which is run all the numbers at the national level based on counties, based on existing service area boundaries that we have in the system now. And we expect that a large number of places will automatically qualify. Nobody will have to do anything. So, it will take burden offstates and communities who now have to submit information to get a designation.

For areas that don’t qualify on that basis, a list will be sent to the states saying, “These areas don’t qualify based on our data. You might want to consider substituting your local data for ours.” And that may be enough to make them qualify. They may want to redefine the service here. Maybe it’s not a whole county, maybe it’s a part of it.

So they can work their way through that process, and another grouping will then qualify. For areas that can’t meet a geographic designation, they have the option still of doing a population designation. Again, that’s going to require local input. Most often, it’s low-income population that will require them to say, “Here’s a low-income population and here are the providers who only – who accept Medicaid or offer a sliding fee scale and to what degree do they do that. You work your way all the way through that, you work your way through the tiers of pulling out the providers from the various safety net options.

And finally, for people who don’t get caught by any of those things, there is a safety net option, and it was specifically added because of concerns about existing safety net providers; an organization would then be judged on its user population specifically; the have to meet two requirements: one that at least 10 percent of your user population is either sliding fee or no fee, and B, either 40 percent of urban areas, 30 percent of rural areas, and 20 percent of frontier areas – a combination of sliding fee, no fee, and Medicaid. So that’s kind of the last chance to be maintained in terms of the designation process overall.

Now, the safety net facility one probably does not apply to rural health clinics. The proposal includes a statement that CMS will not recognize the Safety Net Facility designation for RHC certification. It somewhat like the automatic HPSA situation now, perhaps.

Slide number 30 indicates the phase-in process that, if and when, this thing gets actually published in final, there is a phase-in period of up to three years. Nobody disappears until we’ve sort of gone through that process I just described all the way to the end. We would start with the oldest areas first, which is mostly a lot of the MUAs, which are some cases 20 years old or so.

And that information will be shared with people to to respond, provide new data, and redefine areas in all of those things. So that’s how, generally, the implementation would work.

Slide 37 kind of summarizes what some of the issues were that came up, and then what did we with them, how did we try to address them. The timeline roughly is we’re now in the middle if the
Comment period – it was published on February 29th. The current deadline for comments is April 29th. There has been a request for an extension and at present, the answer to that is no. It is a very tight time frame to get this out by January of ’09, which is the department’s desire. So, extending the deadline makes it harder and harder to do that. So that’s roughly the timeline that’s left.

Summarizing really quickly, we’ve gone from two methods to one. We hopefully streamlined the procedure so that a lot could be done here electronically with our own databases, and people have to do less work at the other end. We do think it’ll improve the targeting. We think we’ve addressed a lot of the criticisms that were made to, you know, the current designations or to the one that was proposed in 1998, or more comfortable that it’s grounded on better science than it was before.

There was a lot of involvement of stakeholders prior to it becoming an official document, because once it becomes that, we can’t talk to anybody about it. But prior to that, a lot of the primary care offices, and some primary care associations with other people were involved in commenting on it. And the safety net option was actually added as a result of some of that input.

And the impact testing, which was much more extensive than it had been in the past, makes us feel pretty comfortable that there’s going to be a relatively minor impact on the existing safety net. I’m never going to promise anybody that there’s not one single clinic somewhere that might fall off the bottom, but that overall, we think it’s a pretty effective tool, and it’s got some safeguards built into it that we anticipate the impact will be, you know, relatively small.

Now, I need to say now that I am not in a position at this point to discuss things that are really comments on the new method. Those kinds of comments need to be submitted through the process as described in the publication itself. We can talk about some of the implementation issues and some of the definition issues in terms of the data and that kind of thing. But I can’t get into a discussion about why didn’t you do this, or why didn’t you do that, or what about this, or I think you should do this. Those are comments, and they need to be submitted through the formal process.
If I think we’re starting to get close to that line. I’ll have to stop and say, “OK, you need to submit that as a comment.” And then I won’t really comment and engage in that conversation.

Bill Finerfrock: OK, what we’d like to do is open up the phone lines for some questions. I had – before we get to the questions from the callers, I did have a question about on the personnel issue you have. One of your slides shows that under the tier two process …

Andy Jordan: Right.

Bill Finerfrock: … the exclusion – it would appear that very few rural health clinics would fall out …

Andy Jordan: Right.

Bill Finerfrock: … once you go through that second-tier process.

Andy Jordan: Right.

Bill Finerfrock: However, I did want to clarify and make sure if you understood. In that tier two process, the current proposal does not recommend exclusion of physicians, PAs, nurse practitioners, or nurse midwives who work in rural health clinics. It would only exclude physicians, PAs, NPs who work in community health centers, National Health Service Corps.

Andy Jordan: As it’s currently written, that’s correct, as well as J1 visa waiver physicians

Bill Finerfrock: OK. And do you – do you have – what databases will you look to or you – do you think you’ll look to with regard to finding those PAs, NPs and nurse midwives?

Andy Jordan: You mean specifically the ones at rural health clinics or …

Bill Finerfrock: Any of those. You know, what we’ve been told is that there are, you know, the state licensing, state databases in terms of where folks practice, or actually any of these, but that the databases for PAs, NPs, and nurse midwives are not as robust as they would be for physicians.

Andy Jordan: That would be putting it mildly. Yes.

Bill Finerfrock: And is there any …

Andy Jordan: That – we recognize that that is a problem. The PA data is pretty good. It’s more like the physician data. The nurse practitioner, nurse midwife data are not very good. There is not a good comprehensive source of information.

So, in that regard, you know, we’ll – we will consider the best information that anybody can provide on that; a lot depends on what kind of state systems are in place in – between the licensure and other sources. And you know, some of it, as we used to do in the old days, it’s the phone book and it’s listen asking the local health department, etc. Now, it’s probably easier in rural areas because they’re just a lot fewer, and people tend to know their territory.

But it is a problem that there is not a comprehensive database for that. So, it’s really, give us the best that you could get, tell us how you did it, where the information came from, what you did to confirm it, modified if you made changes from getting a run from the licensing board and then making some changes in it. There is no good answer to that question, and we recognize that.

Bill Finerfrock: OK, and then second question is – you did your data runs in terms of trying to assess the impact of this.

Andy Jordan: Right.

Bill Finerfrock: I think you mentioned you used ’99 and 2000 data.

Andy Jordan: The testing that’s in the regulation itself, all the data were around that time frame, yes.

Bill Finerfrock: Is there a reason that you used such old data as opposed to more current data?

Andy Jordan: Because that’s when the reg was written, that’s how long it’s been in the clearance process.

Bill Finerfrock: So you – this was internally. That couldn’t have been updated?

Andy Jordan: The problem’s once you start the process, if you go through doing that, you basically have to start over.

Bill Finerfrock: OK.

Andy Jordan: And that’s a problem when something takes that long to get through the process. Now, we did do a limited update last summer. The contractor did a run. We were not able to do all of the same kinds of updates through all the tiers and everything because we didn’t have the time or the resources to do it. The overall impact is roughly the same. The balance between urban and rural, and whatever, are roughly the same as they are in this one. But we did not have a comprehensive update that perfectly matches this one.

Bill Finerfrock: Ok, all right, operator, we’d like to open up the line, and could we have some questions from our listeners?

Operator: Ok, thank you. Today’s question-and-answer session will be held electronically. If you would like to ask a question, please press star one on your phone. Also, please deactivate any mute function before signaling to be sure your signal can reach our equipment. If you find your question has already been answered, you can press star two to re-mute – I’m sorry, to remove yourself from the roster at any time. A voice prompt on your phone line will indicate when your line is open. And we do ask that you please state your name and location before posing your question. Once again, that’s star one to signal.

And we’ll take our first question.

Bill Finerfrock: And if – and just as a reminder, if you please give us your name, and where you’re calling from.

(John Supplit): Hey, this is (John Supplit) calling from the American Hospital Association and I’m in Chicago.

Bill Finerfrock: Go ahead, John.

(John Supplit): Turning to slides 24 and 25, in some ways, though, I want to get clarification on the first question you asked. And that was – in determining or applying the yo-yo factor – studying the yo-yo effect – do we or do we not take out – take into consideration providers at rural health clinics? And then slide 25 seems to suggest that we are.

Bill Finerfrock: Andy?

Andy Jordan: The answer is slide 25 shows the effect on the area of rural health clinics but not of backing out rural health providers. And the issue is at the time it was done, we did not have a database to be able to apply rural health clinic providers to the model. That’s what I’ve been told by the people who were involved in actually developing it at the time. So, it was not tested that way, and it’s not currently written that way.

(John Supplit): The rule is not written that way.

Andy Jordan: Correct.

Bill Finerfrock: Proposed rule.

(John Supple): The proposed rule.

Andy Jordan: Proposed rule.

(John Supplit): Thank you.

Bill Finerfrock: Yes, but this is something that folks could comment on and make a suggestion that be considered by you folks.

(John Supplit): Absolutely, and that’s (spelled out) is kind of where I was going with that because that’s how I got confused when I looked at those two slides. Thank you.

Bill Finerfrock: That’s why I wanted to get it clarified. So – but Andy, would you say that that is something that folks should comment on or …

Andy Jordan: That’s a comment issue, right.

Bill Finerfrock: Yes, OK.

(John Supplit): Thank you, Bill.

Bill Finerfrock: Yes, next question?

Operator: And we’ll next go to …

Bill Finerfrock: Go ahead, caller.

(Lisa Kilui): Hi, this is (Lisa Kilui) and I’m in South Dakota. And I just had a quick clarification. When you do – when you analyze the HPSAs and the MUAs, you didn’t analyze them all, right? You just did the test states, which were North Carolina, Washington, California and New York. You didn’t do anyone in the midwest?

Andy Jordan: No. We did every county in every state. We did every MUA and every HPSA that was on the books at the time.

(Lisa Kilui): OK.

Andy Jordan: Those states did their own testing. We did every state, yes.

(John Supplit): So who has that information? Is it publicly available?

Andy Jordan: I think, Bill – did I send you the state tables? I thought I did.

Bill Finerfrock: I may. I don’t know. I’d have to look. I know I don’t have – I’m not at my computer.

Andy Jordan: OK, there was a summary – a set of summary tables by state that is not part of the reg as it’s published, but that was made available to the state – I will go back and make a comment I should’ve made at the beginning – to the primary care associations’ and primary care offices in the states. I believe I sent it to Bill with the NARHC, and also for the National Association of Community Health Centers, to show the state breakouts.

Bill Finerfrock: If I have that, I will put it out on the listserv.

Andy Jordan: OK, but every state was done. What – and to follow up on that comment, we’ve been encouraging people to comment on the test and write us feedback. And we really encourage people to kind of work collectively. I sure don’t want 3,000 individual rural health clinics and 1,000 individual community health centers and whatever else out there doing this separately on their own. That’s why we’ve kind of channeled the effort and the information to the primary care offices in the state health departments and the primary care associations and with the two national organizations who represent two of the biggest groups of constituents. And we really encourage people to work with those folks.

I know there are a number of states who are doing that analysis and I think that that’s the best way, the most efficient way to kind of pool the issues and the work that needs to be done in terms of testing. So I would encourage you to contact those people in your state. That would include the state office of rural health, many of which are also primary care offices as well, in terms of issues you’ve got or specific issues about testing in your state and see what they’re doing.

(Leonard Nadoff): My name is (Leonard Nadoff). I’m calling from Oregon, and I have two – one simple question. I’m looking at your map on slide 28. Is that the current HPSA, MUA or the proposal after the survey that you’re doing now?

Andy Jordan: What that shows is the results of what called – we call shorthand NPRM two. That’s the …

(Leonard Nadoff): Yes.

Andy Jordan: That’s the results of running the model through a low-income population estimate. So, we basically do the geographic runs and then estimate that some number won’t make that but they’ll make a population group and try to estimate what that is, which is very difficult in national levels.

(Leonard Nadoff): OK and my second question is about HPSA bonuses, if you’re willing to talk about that. I know that rule helps. Clinic services themselves are not entitled to HPSA bonuses, but I wanted to clarify if a physician in a rural health clinic or provider in a rural health clinic visits a patient in a hospital or in a nursing home and provides those services, are they entitled – does that service – is that entitled to the HPSA bonus?

Andy Jordan: If the area is designated as a geographic, whatever this is going to be called when we’re done …

(Leonard Nadoff): Yes.

Andy Jordan: … it would be just like now being a HPSA and being eligible for the bonus.

(Leonard Nadoff): OK, but currently we still fall under the old rules until this becomes finalized.

Andy Jordan: And if and when this becomes real, geographic designations under this method will also be recognized by CMS.

Bill Finerfrock: But the – but you don’t handle the bonus payment.

Andy Jordan: I don’t want to have anything to do with it. No.

Bill Finerfrock: That is strictly a CMS …

Andy Jordan: CMS issue.

Bill Finerfrock: … and for rural health clinics, the bonus payment would only apply to Medicare services that you provide that are non-rural health clinic but billed through the Medicare fee schedule for – that would otherwise qualify if it met the geographic criteria.

Andy Jordan: Right.

Bill Finerfrock: That is a CMS. All Andy does is work on what are or are not considered shortage area designation, how Medicare uses that for who gets the bonus payment as dictated by the Medicare law, which is not something Andy has anything to do with.

(Leonard Nadoff): All right, thank you very much.

Andy Jordan: Doesn’t want to. That’s correct.

Operator: And then we’ll go next to …

(Brian Benchunter): Hi, this is (Brian Benchunter) in Ohio.

Bill Finerfrock: Hi, Brian, go ahead.

(Brian Benchunter): I just want to make sure that I understand slide 29. And I – I’m part of a rural health clinic, a private office. And where my concern is that – and I understand what you’re saying, Andy, that rural health clinic docs and PAs are – would not be excluded from the counting. But essentially, if I heard you right, you’re saying that in 29, steps one and two would apply to rural health clinincs. But essentially, step three does not.

Andy Jordan: The answer to that is a rural health clinic that could qualify as a safety net facility – the question is what CMS does with that designation, because right now, for example, they don’t recognize HPSA-designated facilities and eligibility. So, it’s one of those things that any kind of private non-profit practice that meets the criteria for safe – for safety net options could meet that.

Let me give you an example that might – that might clarify the difference.

(Brian Benchunter): Sure.

Andy Jordan: In states Nebraska, Kansas, and approximately 10 other states that use a state certification for rural health clinics, as well as the national ones?

(Brian Benchunter): Yes.

Andy Jordan: Because there’re areas in those states that aren’t HPSAs or aren’t MUAs, but the state has a methodology which has been approved, and they’re already qualified. That facility is a rural health clinic because it’s in one of those recognized areas and CMS recognizes that. That facility could qualify for the safety net option under this rule if it meets those criteria, and therefore it would be recognized as a HPSA for the purposes of the National Health Service Corps where otherwise it would not be.

But a facility that is a safety net option designation only, CMS won’t recognize that facility designation to make it qualified to be a rural health clinic. It’s my understanding that they – they’re looking at geographic areas for qualification. And that’s a facility, not a geographic area.

(Brian Benchunter): That helps, thanks.

Andy Jordan: That helped.

(Brian Benchunter): Yes.

Andy Jordan: It’s a little confusing.

(Brian Benchunter): But they – the key is that under that tier two process, the personnel from the rural health clinic are not excluded from the count.

Andy Jordan: Correct.

(Brian Benchunter): So the count that is most significant currently under the proposal would be the tier 1 process, which is your aggregate primary care physician, primary care PA, primary care NP ratios.

Andy Jordan: Well, and and National Health Service Corps people or J-1 as that becomes significant.

(Brian Benchunter): Those would be removed from your counts.

Andy Jordan: Oh, it’s going to be removed in the tiers. Right.

Bill Finerfrock: Next question?

(Cherry Lang): Andy, this is (Cherry Lang) from North Dakota.

Andy Jordan: Yes, hey.

(Cherry Lang): How are you doing?

Andy Jordan: Hey, how are you?

(Cherry Lang): I have – one question that I have is in regards to the conversion. Many of the areas may convert over to population HPSAs. That we’re looking at due to the significant use of midlevels within our rural health clinics.

Andy Jordan: Right.

(Cherry Lang): This is something that I – currently under the current rules, CMS does not recognize population HPSAs. Is that correct? I’ve got …

Bill Finerfrock: No, that’s not correct. HP – population HPSAs are recognized by CMS for purposes of the Rural Health Clinic’s program. Medically underserved populations are not, and that has to do with the way the underlying rural health clinic’s statute is written, where it specifically references areas designated as a shortage area by the public health service, but then encompasses all shortage areas, but then makes only specific statutory reference to medically underserved areas. So a population HPSA does qualify for rural health clinic designation.

(Cherry Lang): So therefore, would a population HPSA continue to qualify for rural health clinic certification status? In addition, will they separate out tier one and tier two geographic?

Bill Finerfrock: Well, again, those are issues that are at one level a CMS issue, but are dictated by the statute. But the underlying rural health clinic statue has not changed, so as long as an area has a health professional shortage area designation, regardless of whether it’s population or geographic, it would continue to qualify for rural health clinic designation.

(Cherry Lang): Really. Because I – I’ve never seen any documentation on the population, though I had only seen documentation that it only accepted geographic.

Bill Finerfrock: Yes, it accepts both population. It has to be a HPSA population – can be a medically underserved population, can be a MUP. But it can be a HPSA population.

(Cherry Lang): OK. Is this Bill?

Bill Finerfrock: Yes.

(Cherry Lang): Can you send me that?

Bill Finerfrock: Sure.

(Cherry Lang): Thank you.

Bill Finerfrock: Send me an e-mail with your address – your e-mail.

(Cherry Lang): I will do that. Thank you.

Bill Finerfrock: Thank you.

Operator: And we’ll go next to …

Bill Finerfrock: Next question.

(Eric): Yes, hi, this is Eric from New Hampshire. Hi, Andy.

Andy Jordan: Hi, hi, Eric.

(Eric): I was wondering. Could you clarify a little bit more how the low-income designation process works under these new rules because the way I read it, it says that the high-need indicator portion will be calculated based on the values for the applicable population group?

Andy Jordan: Right.

(Eric): So does that mean that essentially if we do a low-income designation, that that first criteria, the percentage below 200 percent of poverty, would that essentially be able to get 100th percentile score? ((inaudible))

Andy Jordan: My understanding of it, yes.

(Eric): And then beyond that, you’d be able to apply adjustments (and to say) …

Andy Jordan: To the extent feasible; it says, “Get as close as you can to the population.” Obviously you don’t collect infant mortality data by income. So, you’re not going to be able to have a perfect fit between the low-income population and some of the factors. But to the extent that you can get as close as you can, that – that’s what they’re asking for

(Eric): OK, so across that whole spectrum, we could apply – if we have research showing a link between, say, you know, low income and a certain increase in the percentage of, say, unemployment – that we’d be able to apply that factor.

Andy Jordan: Yes, I mean – yes, to extent that provide the information, what’s it based on and that kind of stuff, yes.

(Eric): Yes, OK, because that seems like it could lower the threat. Is that what was done when they tested the low income method?

Andy Jordan: No. I mean that’s why, you know, that was a pretty blunt instrument. What they did was basically provide an adjustment on the FTEs– and I’d still like to try to get clarification on one piece of this. They adjusted the FTE figure by a multiplier of 0.21 as a rough estimate of sort of the average provider accepts, the low-income population the level of 0.21. And don’t ask me to cite you the source for that information.

(Eric): Right. Because that – yes, on that table – and essentially just for getting 100th percentile on low income, they’ll get 1400 practically out of a 3,000/1 ratio …

Andy Jordan: Right.

(Eric): … sort of off the top. So, OK, thanks.

Bill Finerfrock: Let me throw a – ask a question before we go back to the callers. Could you explain, Andy, on a little bit more the PA, NP, CNM is counted at a 0.5 FTE …

Andy Jordan: Right.

Bill Finerfrock: … ratio.

Andy Jordan: Right.

Bill Finerfrock: That number could be adjusted.

Andy Jordan: Right.

Bill Finerfrock: Can you explain how that adjustment would work and …

Andy Jordan: I can try.

Bill Finerfrock: … how it gets triggered …

Andy Jordan: Yes.

Bill Finerfrock: … or when it gets triggered?

Andy Jordan: You know, this is – this is a very difficult issue. As you could imagine the real implications and the political implications and all of that involved in this conversation. The original 0.5 is what was used in the testing, and, that’s kind of where we started.

Obviously, there are people who consider that insulting, and professionally, you know, not very positive. And the – sort of the next step was put in as an option to kind of acknowledge that there are places where the role is significantly greater than 0.5, but not wanting to penalize people in states where the roles are really very small.

And the research that had been done by (Sekscinski) at the time – and has since been updated once anyway – of trying to measure kind of the equivalent based on the scope of practice within a given state, to be able to account for the full impact of these practitioners. Why would anybody want to do that? Their numbers might go up? We acknowledge that; it’s an issue, but it was important to build in something to acknowledge that the roles of those practitioners, it’s not always at 0.5. So, it’s really looking at how those numbers play out in your given state , what’s the multiplier, what’s the scope of practice and that kind of thing, depending on where you are.

Bill Finerfrock: Could it ever go below 0.5 if you had a state – I don’t know that we do, but if you had a state that had a fairly narrow or conservatively drafted scope of practice for a particular discipline, that you would determine that it’s less than 0.5?

Andy Jordan: I’d have to go back and look at it to see exactly what the intent was when they wrote that.

Bill Finerfrock: OK, all right. I was just – I was curious. OK, operator, we’ll go back to the phone calls.

Operator: OK, and next question?

(Jim Dixon): This is (Jim Dixon) from Copper Queen Hospital in Bisbee, Arizona on the border with Mexico and Arizona. Is there any way we can get a copy of these maps to see the before and after, allow the (ajuda) or painfulness that this is creating – is that, you know, we’ve created these systems, Andy, based upon these designations because of the huge inundation of over 1.5 million immigrants, which I’m going to comment on in the model. I think that’s important that we recognize that we’re in the middle of this storm that comes across the border.

But a lot of us are not as fluent in these definitions and these calculations.

Andy Jordan: Yes.

(Jim Dixon): And all we know is that if we lose it, we’re not going to have any doctors because all the doctors in our area have left. The only ones that are left are the – in the RHCs. And so is there some way – directly my question – is there some way we can get a copy of the map before and after? And then what’s the specificity to our state and by county?

Andy Jordan: The answer to that is twofold. One, that – that’s actually the only map I have. And I don’t know that the people who did the work have a different map either. The real answer to the question is that map reflects work done in 2000, 2001.

(Jim Dixon): Yes.

Andy Jordan: And it’s really not very valid anymore. And that’s why when we’re telling people to test it now and comment. We’re saying, use more up-to-date data that reflects the current reality and not recreate what it was then.

So, I would be worried if you were using that information which is now six or seven years old and using that as a basis for making any assessment of anything, that the work that people are doing in the states now – looking at current data that they have available, particularly the FTE information, because that’s very difficult at any national level – will be a much more realistic picture of what’s really going to happen with this. So, even if I had a map, I’m not sure it would be that useful to you.

(Jim Dixon): Yes.

Andy Jordan: It’s really more, within that state, looking at the information in those counties and those areas. You’re talking about along the border and what the – what do the data show, based on, the more recent and more locally founded information. That would be more realistic.

(Jim Dixon): The second part – I’m glad to see that you’ve included some state input. One of the things that’s very fearful to us here is – in Arizona especially – is changing this. And our situation is so different compared with tribes and migration and Hispanic populations and having state input, being able to have the state do something. That’s very important in this process.

I’m going to ask, you know, the question. Everyone has a little more time to study this. That’s the other side of that. But it is creating a lot of expectations of not being there and then decimating the system and then going back.

But I’m glad to see that you got some time here to comment. That’s all I have. Thank you.

Andy Jordan: I think it’s important for people not to panic. And take a deep breath and, you know, run the numbers and see what happens and not assume that any change is always is worse and not better. There is a huge potential if somebody ever asked us to rerun the numbers for the existing MUA designations with the existing criteria, you would see an empty map, because there’s no way most of the places currently designated as MUAs would qualify anymore.

We’ve had some states who have done that test and have been not happy with the outcome and, have sort of stopped. So, there is a potential that – because it happened in 1980 and it can happen again, that somebody says rerun the numbers with the existing criteria. Then you will see a panic.

Well, it’s very important for people to realize there are other potential outcomes that can happen, and actually that in the regulations, in the publication itself, it shows you the results of redoing the current methods and the percentages of areas and sites that drop out, if you just did that. And that is always going to be out there as a possibility. And, you know, you have to consider that when you’re thinking about, well, is it better to do nothing? Because if you do nothing and somebody comes back and says, “You need to run these numbers this way,” that’s going to be a real problem.

So, you have to look at both sides of that. But I really – particularly in the rural areas –the people who worked on this were so acutely aware of the rural issues that they really went out of their way to look at that. And again, the first impact testing does not indicate huge problems in that area. And again, this testing is probably still pretty gross testing, and local information would make a big difference.

So before people start to panic, take a deep breath look at the numbers. And we couldn’t do this without the states. They’re critical parts of this. They were involved in the development and they’re very heavily now involved in looking at how it plays out in their states and making comments based on that. They’re a huge part of the process.

(Bill): Andy, I do – I want to jump in there a second. I think that we’ve had a lot of discussion, a lot of questions are, you know, what is the impact in looking at the numbers? And I think that looking at the numbers is important in terms of understanding what the impact would be. But my – I’m concerned that folks will become so fixated on the numbers that they won’t look at the policy.

And you will need to keep in mind that the underlying policies that lead to these numbers will be here for a long time. And you need to look at what is being proposed, what kind of factors are being proposed for consideration and being examined, what factors weren’t included in the formulas. So, while the numbers will give you a snapshot and tell you what the impact may be in 2007 or potentially in 2008, the policy is going to be in place in 2015, 2020, 2025.

And so we also want to make sure that we get the policy right. And so while we encourage folks to run the numbers and to look at the numbers and set the impact in the near term, it’s equally important that you look at the policies that are being proposed to make sure that we’re getting it right for the long term.

Andy Jordan: OK, can I quote you on that? Because you’re the first person who has made that statement in all the conversations I’ve had about this. And we’ve been so focused on – “run the numbers.” Because people are so panicked about that, they’re not looking at what you’re saying. And what you’re saying is much more important. You’re absolutely right, but people can’t get there because they’re jumping off the cliff.

(Bill): Right, and I understand – I’m not saying don’t run the numbers and don’t react to the numbers.

Andy Jordan: Right.

(Bill): But don’t do it to the exclusion of looking at the policy.

Andy Jordan: You’re absolutely right. That’s really – the long-term more important issue. And to the extent that we can get people to accept it, that’s really important. I appreciate you saying that because you’re absolutely right. You’re the only person that said that.

(Bill): Well, thank you.

Bill Finerfrock: OK, next caller?

(Les Lacey): This is (Les Lacey) calling from Cayenne County Hospital at Saint Francis, Kansas. We operate two rural health clinics and have the hospital here. And we’ve had a historic problem with physician instability, that we seem to be getting a handle on.

My question is, on backing out the National Health Service Corps candidates, I’m thinking you’re talking about both the scholarship and loan repayment candidates – and the question is, is – does that include the ones who have received it in the past? Are they continually marked out of the count, or do they come back in to it? Do they reappear once they have taken money?

And the reason behind that is when we do that, when we got our first candidate here, that was the only physician in our county, and so that’s an enormous call load for a lone physician. And we felt like until we had a second physician, we had an unstable area here. And so I’d – I just like you to respond to that.

Andy Jordan: No, I mean that’s an interesting point. There’re really other people who ask that question. The principle is that people who are there specifically because of a designation are exempt from the count. When someone’s obligation is over, they’re not there because of the designation.
Now I – I’m not dismissing what you’re saying and saying that’s not a legitimate issue. But the policy is if they’re there because of a designation, be it on a national service corps person, or, you know, state loan repayment person, a J-1 person, or people working at a health center, they’re there, and you make the same argument about rural health clinics – they’re there because the designation is there or an obligation is there or something like that.

Once that person doesn’t have any connection like that, and they become a private practitioner, whatever, they’re not – they no longer have that connection. That – the principle always has like that..

(Les Lacey): So the policy then, what that does is that, you know, that eliminates the early term, the short-term yo-yo. But over a longer term, you know, if we establish a stable physician here, then we wind up penalized for that because when that stable physician loses their support, we lose the, you know, all the – all the backing behind that. And we’re not able, then, to maintain our designations so that we can continue to have a stable healthcare system. That’s our point.

Andy Jordan: Well, as I mentioned to some people on the call yesterday, remembering that this is a measure of relative need. It is not a measure of absolute need. And, we had a conversation earlier today about trying to change the way people think about things-that losing a designation is actually a good thing.

Now I understand in that within the community that’s an issue. But there are other areas that are worse off. And this is an attempt to identify areas of relatively greater need than others. And, no one is perfect, and – but then there’re always going to be some people who they’re absolutely convinced that they have these great needs. But relative to others, the need is not that great. The people in Vermont, New Hampshire and in New England right now are not very happy with me at all.

But quite frankly, would I compare them to the border areas you all were talking about and some other areas? I think it’s hard for them to make the case that relatively they have that significant a need. That’s not to say that there are not areas there that have need and populations that have need. But this is a measure of relative need. And relatively, you know, for that community, you’re right, it may be unstable at that point, but relatively, that’s lesser need. I mean that’s just the way, almost any system that measures relative need would be designed.

But I understand what you’re saying. And if is there a comment that would be appropriate to address that, then I would certainly make them as part of the comment process, as a way to deal with that kind of an issue.

(Les Lacey): Thank you.

Bill Finerfrock: OK, next caller? Go ahead, caller.

(Maili Per): Oh, sorry. Hi. This is (Maili Per) from Hawaii. Andy, I wanted to ask a few questions about slide 29 and 32. First on 29, the step one national data calculations for geographic areas – geographic areas – does that mean you’re going to run the data for the MUAs – or, I’m sorry, the MUPs and the geographic HPSAs?

Andy Jordan: What will be done is based on any geographic definition we have, which will be counties, which will be existing MUAs, existing HPSAs either geographic or population.

(Maili Per): OK, OK.

Andy Jordan: Those areas that have a boundary.

(Maili Per): That’s everything. OK.

Andy Jordan: Or states that service areas. We will run those too.

(Maili Per): OK. And then what’s – what are sort of the timelines for that? Like when would you guys do one? And then how long do we have to do two …

Andy Jordan: Some – there’s some description of timelines in the reg itself.

(Maili Per): Oh, OK.

Andy Jordan: Yes. But the other answer is, we’re not sure because we really don’t know how long, some of it is going to take. There are some time frames laid out in the regulation.

(Maili Per): I – and that’s why I had the slide 32, whereas that – where you have that timeline for final rule. I was just wondering how …

Andy Jordan: Just to get the rule out. That doesn’t talk at all about what happened afterwards.

(Maili Per): So this is what’s going to happen after the rule, the implementation three-step process.

Andy Jordan: The case is after it’s public, if it gets approved in final

(Maili Per): After – OK, after.

Andy Jordan: But then when it gets public.

(Maili Per): Very good – and then one last question on the slide 29, the step two where it talks about the state submitting data. So that implies that by the time we’re doing that for – to send to you, we’ve already designed or redesigned our service areas.

Andy Jordan: Yes, it would basically be after we do one and there are some parts of Hawaii that don’t make it …

(Maili Per): Right.

Andy Jordan: … they – OK, these don’t make it based on our data. And that – yes, this is the area we ran, and this doesn’t make it. And you can then come back and say, “Use the same area but you substitute my FTE for yours.”

(Maili Per): OK.

Andy Jordan: For example, the FTEs went from 6 to 2.4.

(Maili Per): OK.

Andy Jordan: Guess what. They made it. Or you can come back and say, “You know, the whole county is never going to work and it’s really not right, but let’s look at the service areas.”

(Maili Per): OK.

Andy Jordan: That becomes more like what we do now.

(Maili Per): OK.

Andy Jordan: That point. Yes.

(Maili Per): Very good. Thank you.

Bill Finerfrock: Next caller?

(Chris Sparks): This is (Chris Sparks) with the Washington State Office of Rural Health, and I have maybe a question for Bill and then one for you, Andy, on the safety net facility option sort of if it does apply to rural health clinics. Is that a site-specific? Does each clinic – or if you’re partnered by a larger network or a larger system, do those thresholds apply to the total system, or is it clinic by clinic?

Andy Jordan: Well, I’ll give you the answer of that – that I understand, and this is – this is sort of based on the way it’s been done for the automatic HPSAs, that for rural health clinics, our understanding is that CMS recognizes each individual site separately. And that’s probably the way it would be done. If that’s wrong, then that’s information that we were given, you know, when we set up the automatic HPSA process.

Whereas for FQHCS, they’re recognized by CMS as one organization, and the bureau recognizes them as one organization. So they’re dealt with as an entity, including all the sites within their approved scope. So they’re dealt with differently now because they’re defined differently by other people. It was not a definition that we make. It’s a definition others make that we follow. So, unless, we know differently, we would probably follow that same pattern. And it would be site specific for rural health clinics.

(Chris Sparks): OK, thank you. And Bill, your comments about what the federal statute says about rural health clinics and whether they’re in HPSA or not, I was thinking that CMS would have – potentially have the authority to continue to pay a rural health clinic that met the safety net facility criteria. But now, based on your comments, I’m wondering, is – would that be allowed under the rural health clinic authorizing statute, or would there need to be a change to that federal statute to allow if a rural health clinic continued, was no longer in the HPSA, but did meet these safety net facility criteria, could they continue to be paid? And who’s – I guess – does it take a federal law change, or is that a decision CMS has?

Bill Finerfrock: There are – there’s two different issues here. What (person) and then the (sharpness) I’m sure this designation is doing is that their criteria, their changes would affect those areas for which an RHC qualifies or could continue to qualify based on the shortage area designation.

Separate from that, CMS is in the final stages of writing proposed rules that will have in there a process by which clinics that are no longer in a health professional shortage area or medically underserved area can stay in the rural health clinic’s program if they can demonstrate based on the – what will be proposed criteria, that they are essential to the availability of care in their community. CMS would have the authority under that, depending on what they chose to do to recognize a safety net facility for purposes of continuation.

So – but the safety net designation would not be appropriate for becoming a rural health clinic. So if you had a facility that went in and obtained exclusively a safety net designation, that would not be a basis for which they could become a rural health clinic. But if you had a rural health clinic that subsequently got a safety net designation, CMS’s process could recognize that safety net designation for continuing. That will be part of the CMS rule-making process, and we don’t know how that’s going to go.

(Chris Sparks): OK, thank you.

Bill Finerfrock: Next. Excuse me. Next question?

(Deb Janke): This is (Deb Janke) from the Minnesota Office of Rural Health and Primary Care. I had two questions, Andy, if you could just clarify on that safety net facility designation. Is that HPSA only, or is that going to result in an MUA qualifying designation for those facilities?

Andy Jordan: If you read the regulation very carefully – and I had to dig this out myself – the people served by that safety net facility are a medically underserved population and therefore eligible for 330.

(Deb Jenkins): OK, and I’ve rather carefully – I …

Andy Jordan: Oh.

(Deb Jenkins): … I can tell you. Of course …

Andy Jordan: It took some digging.

(Deb Jenkins): Yes.

Andy Jordan: So I talked about the panic at one point and went, “Oh my goodness. Wait a minute. We’ve been wrong about this.” And then I kept reading and go, “Oh, there it is.”

(Deb Jenkins): OK. And then my next question is if you could clarify under the section where it talks about tier one and tier two …

Andy Jordan: Yes.

(Deb Jenkins): … and how tier two areas would be able to maintain resources that only tier one would be eligible for new resources. Can you define resources? Is that just talking about National Health Service Corps? Are we talking about grant funding, National Health Service Corps, J-1, et cetera?

Andy Jordan: Those are really programmatic implementation questions that I can’t answer. But from the standpoint of the development of the model and the possibility, the concept was that if you have, if you run a number of areas and there are areas that fall above the line and therefore are underserved when you’ve got every possible resource you could think of that are in there, then those will be logical places to target additional resources to. I mean they don’t have any resources in them now.

But even if they do have resources but they clearly still have needs even though all those resources are counted. And so that might be one thing you might want to think out in terms of targeting. Then have areas that only qualify when you back out the existing resources – the health center people and/or the corps people and/or the J-1s – then you might say, “Well, you don’t want to pull those mixed resources out” because they’re bringing that community up , they’re taking them below the line and therefore not in need.

But you may not want to add new resources to that because, relatively, they’re not as needy as the other places. But those are all programmatic implementation issues that program will decide how they will use that information in their decisions.

(Deb Jenkins): And when you’re talking programs, you’re talking like the J-1 program will decide how they want to do it.

Andy Jordan: Health centers, the National Health Service corps …

(Deb Jenkins): Yes.

Andy Jordan: And whoever it is that runs the J-1. Yes.

(Deb Jenkins): All right.

Andy Jordan: Yes.

Bill Finerfrock: Operator, we’ve gone a little bit over. Do we have still questions in the queue?

Operator: Yes, sir, we do still have about seven more.

Bill Finerfrock: We – Andy, can you go a little bit longer?

Andy Jordan: If they’re not too long, yes.

Bill Finerfrock: OK. Yes, we’ll take a couple more and – but then we’re going to have to – I know you’ve got a meeting coming up, so take a couple more questions.

Operator: Thank you, sir. And we’ll take our next question. Please go ahead.

Bill Finerfrock: Go ahead, caller.

(Tom Rauner): Hi, this (Tom Rauner) from Nebraska. I want to go ahead and ask a question as will the Governor’s eligible areas for rural health clinics still be an option for rural health clinic designations as they are now?

Andy Jordan: This doesn’t have any effect on that.

(Tom Morris): OK, so they will remain?

Andy Jordan: That’s in somebody else’s statute.

Bill Finerfrock: I didn’t hear the question.

(Tom Morris): Basically, when states can go ahead and request eligible areas for rural health clinics from the governors?

Bill Finerfrock: Right.

(Tom Morris): Eligible area option?

Bill Finerfrock: Right.

(Tom Morris): I was just wondering if that was going to be impacted by this.

Bill Finerfrock: No. As Andy said – and the – it’s a separate section of the statute that recognizes the governor’s authority separate and distinct from a HPSA MUA. That hasn’t been changed. The only thing is that they would continue to have to be current, which the rural health clinic program requires that they can’t be more than three years old. So the governors would have to keep those up to date, but nothing here would change the recognition that’s already been granted to states such as Nebraska for purposes of establishing shortage area designations separate from that.

(Tom Morris): OK, thank you.

(Andy Jordan): OK.

Bill Finerfrock: Next question?

(Pat Moynihan): This is (Pat Moynihan) from the Wyoming Primary Care Association. I just have a question about the timeline for coming into states and doing the review, and then whether or not the states would have any say in terms of what areas should be reviewed first.

Andy Jordan: They can – they can have input into that. Yes.

(Pat Moynihan): OK, and what would be the process for that, Ma’am?

Andy Jordan: There’s some description of that in the reg itself.

(Pat Moynihan): OK.

Andy Jordan: You know, without reading it, I know it talks about, you know, the give-and-take that goes on at that time.

(Pat Moynihan): OK, and what’s the timeline then to begin those assessments and reviews of the current designations?

Andy Jordan: Again, if it gets published in January, there are a number of questions about, are we going to have all the systems here ready? The start of February, the answer is probably no. You know, you’re in a real dilemma of how much work you do to get ready if you don’t actually know what’s going to happen.

(Pat Moynihan): Yes.

Andy Jordan: We sort of have been holding off for a long time because it’s going to take some significant, you know, work to redo the computer system and a bunch of other things to make this all happen. And how far do you go? So if it comes out in January there’s going to be some delay before we actually start to implement it. Now, we might be able to do some of it, with some outside help initially.

And then there’re time frames in the reg itself, in terms of 90 days this and that. But nothing will happen immediately. Nobody will be affected till everybody’s had a chance to work all the way through the system.

(Pat Moynihan): OK.

Andy Jordan: Nobody’s going to be dropped right away and then have to get back. Nobody would be dropped until you go through all the steps.

(Pat Moynihan): OK, thanks a lot, Ma’am.

Bill Finerfrock: And this will have to be the last question.

(Carrie): Real quickly, this is (Carrie) from Dakota again, and question on population designations. Will there still be two tiers?

Andy Jordan: Yes, they can still work the same way.

(Carrie): OK.

Andy Jordan: Yes.

Bill Finerfrock: Ok, we’re going to have to wrap it up. I want to thank everybody for participating, and strongly encourage those of you who have been participating, in particular, individuals who represent states or organizations or larger systems, to take the opportunity that we have now to comment on this formal rule-making process. Get your ideas, your suggestions, your reactions in to the addresses that were provided in the federal register so that Andy and her staff and her colleagues have benefit of your reaction, your insight into what’s being proposed here.

This is a very significant proposal, I think, that the participation we had here and the number of questions we’ve had are indicative of the seriousness of what’s being put forward. I want to thank Andy for taking the time to be with us here today, and all of our participants. I also want to thank the Office of Rural Health Policy for their ongoing support of the Rural Health Clinic Technical Assistance series.

A transcript of today’s call will be available on the ORHP Web site hopefully in a week or so. We would like to be able to turn that around. We also will make an audio recording of this, and that typically is available within about 48 to 72 hours of the completion. And that, too, will be available on the ORHP Web site. So if you know people who would like to listen in or you want to go back and listen in, the audio recording of that will be available on the ORHP Web site.

The next call for the Rural Health Clinic Technical Assistance series will be May 13th. We have not identified the topic yet, but that will be out in the not-too-distant-future and will be distributed via the listserv. If you have suggestions or ideas for topics for future calls, please feel free to send them to me at info@narhc.org. That concludes today’s call. And again, thank you all for participating.

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