The purpose of this Policy Information Notice (PIN) is
- to
clarify the Bureau of Primary Health Care's (BPHC) position with
respect to affiliation arrangements that involve community and
migrant health centers contracting for the services of a Chief
Financial Officer (CFO), Chief Medical Officer (CMO) and/or the
majority of its primary care clinicians, regardless of the type
of entity with which the health center is affiliating, and
- To
clarify the BPHC’s review process for affiliation arrangements.
The BPHC is allowing for situations where community and migrant
health centers (C/MHCs) may not directly hire staff in the
positions described above. (The requirement that the health
center directly employ the Executive Director remains in effect.)
The BPHC recognizes that there are certain situations in which
exceptions to the BPHC’s preference that health centers directly
employ personnel to fill these positions (CFO, CMO, clinicians)
may be necessary and appropriate in order to maximize access to
comprehensive, efficient, cost-effective, and quality health
care. The BPHC is committed to allowing exceptions to the
preference upon community and migrant health centers assurance
that its accountability is maintained. Accountability, as well
exception is approved and implemented to assure that the center
continues to meet its mission, Federal requirements, and program
expectations. This PIN sets forth criteria for reviewing requests
for exceptions to the BPHC's preference that the health center
directly employ its CFO, CMO and/or its core staff of full-time
primary care providers. The PIN also explains the review process
for determining whether affiliation arrangements are in
compliance with PIN 97-27 and this PIN.
The BPHC’s decision to grant exceptions to the preference that
C/MHCs directly employ its CFO, CMO and its core staff of full-
time primary care providers is premised on the following
assumptions:
- The health center’s mission to provide access to
comprehensive health care services to the underserved
and vulnerable populations will be maintained and/or
expanded through appropriate health center affiliations
which further the development and operation of
integrated health systems.
- C/MHCs will maintain compliance with integrity and
autonomy requirements while participating in integrated
health systems that enable health centers to achieve
their mission. The health center’s continued
accountability to the BPHC will need to be documented.
- Each C/MHC will conduct its own assessment and draw
conclusions from within their own situation and
environment as to whether program viability is
maintained and programmatic benefit is derived from
such arrangements.
Federal requirements and policies regarding community and migrant
health center accountability are derived from Section 330 and
implementing regulations, Department of Health and Human Services
(DHHS) administrative regulations and binding DHHS and Public
Health Service (PHS) grants policy. The BPHC will approve
exceptions with respect to staffing arrangements based on health
center maintenance of accountability in the following areas: 1)
operating the grant-approved project; and, (2) expending grant
funds in accordance with applicable rules.
Affiliation arrangements will be reviewed against the following
criteria:
- The health center has reserved sufficient rights and control to maintain overall responsibility for the direction of the project, as originally funded, and for continued accountability to BPHC.
- The health center has provided justification for the performance of the work by a third party, showing that the work cannot be more efficiently and effectively performed directly by the grantee.
- The health center has in place appropriate systems and processes to assure that the contractor will satisfactorily perform all contract activities in accordance with section 330 requirements.
- The C/MHC has documented that the written agreement with the
contractor complies with current DHHS administrative
requirements in the following areas:
- contains appropriate provisions around the activities
to be performed, time schedules, the policies and
procedures to be followed in carrying out the
agreement, and the maximum amount of money for which
the grantee may become liable to the contractor under
the agreement;
- requires the contractor to maintain appropriate
financial, program and property management systems and
records and provides the health center, DHHS and the
U.S. Comptroller General with access to such records;
- requires the submission of financial and programmatic
reports to the health center;
- complies with Federal procurement standards (including
conflict of interest standards); and
- is subject to termination (with administrative,
contractual and legal remedies) in the event of breach
by the contractor.
To assure that affiliation agreements comply with requirements
for funding it is important that the BPHC review affiliation
agreements and determine and monitor compliance with the policies
in PIN 97-27 and this PIN. When applicable, C/MHCs will
complete a C/MHC Affiliation Checklist (see Attachment) regarding
affiliation arrangements as part of their continuation
application. Through the C/MHC Affiliation Checklist, the health
center will identify relevant reference documents (e.g., Articles
of Incorporation, by-laws, contracts, affiliation agreements,
memoranda of understanding, other), and specific citations within
them, that demonstrate compliance with the accountability
requirements in PIN 97-27 and this PIN. The BPHC will review
these completed checklists along with the documents as part of the application review process. The results of the BPHC’s review
will be communicated with the continuation application decision .
Health centers will be afforded an opportunity to resolve any
outstanding issues related to the affiliation agreement.
In those instances where it is necessary to request a review for
compliance of a new affiliation arrangement or significant
changes in an existing affiliation arrangement during a given
budget period, the grantee should submit the Affilitation Checklist along with supporting documents to the Office of Grants
Management for review and approval in accordance with the BPHC’s
process for post award requests. The BPHC is committed to
providing feedback within a thirty (30) day period.
For Federally Qualified Health Center Look-Alikes, affiliation
reviews will be coordinated with the designation and
recertification processes.
The review of the C/MHC Affiliation Checklist and accompanying
documentation will be overseen by staff of the Division of
Community and Migrant Health and will involve the applicable
Field Office staff. Health centers are strongly encouraged to
obtain consultation on draft documents prior to submitting final
documents through the review process.
After the exceptions have been approved, the BPHC will monitor
the overall impact of the affiliation arrangement on the C/MHC’s
performance. Through existing monitoring systems the BPHC will
assess the accountability of the grantee, as well as the
programmatic benefits from the affiliation arrangements during
Primary Care Effectiveness Reviews, diagnostic and other reviews.
The programmatic benefit assessment includes the following areas:
- continued or improved access (i.e., increased capacity
evidenced by additional services provided and/or more people
served);
- improved expertise (i.e., management, financial, and/or
clinical);
- increase in capital (i.e., increased working capital,
improved
infrastructure, more efficient use of available
resources); and/or
- maintained or improved quality of care (i.e., improved
services, as measured through patient satisfaction, and/or
improved care, as measured through improved health
outcomes).
COMMUNITY AND MIGRANT HEALTH CENTER AFFILIATION CHECKLIST
Organization: _______________________________ |
Grant # _____________________ |
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(where applicable) |
TYPE OF ARRANGEMENT: |
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_____Merger |
_____Acquisition |
_____Parent Subsidiary Model |
_____Establishment of a New Entity _____Jointly Owned or Directed Jointly (eg. Network corporation) by a Health Center and an Affiliation Partner
_____Contract for a substantial portion _____Other (describe) of the project
Name and Type of proposed Affiliate Organization(s): ________________________________
ELEMENTS OF PROGRAM ACCOUNTABILITY:
Check “yes” if in compliance and “no” if not. Identify reference documents and appropriate page number, and attach copies . Attach explanations for any “no” responses.
GOVERNANCE :
The Health Center Board structure is in compliance with requirements. YES ____ NO ____
Reference
Document Page #
C board composition _____________ ______ C executive committee function and composition _____________ ______ C selection of board chairperson ___________________ C selection of members _____________ ______
The health center’s Board retains its full authorities, responsibilitie s
and functions as prescribed in legislation/regulations. YES ____ NO ___ _
Reference
Document Page #
- strategic planning _____________ ______
- approval of the annual budget of the center _____________ ______
- directly employs, selects/dismiss and evaluates the CEO _____________ ______
- adoption of policies and procedures for personnel _____________ ______
- and financial management
- establishes center priorities _____________ ______
- establishes eligibility requirements for partial payment of services _____________ ______
Organization: ____________________________ |
Grant # _________________ |
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(where applicable) |
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Reference |
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Document |
Page # |
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provide for an independent audit |
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evaluation of center activities |
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adoption of center’s health care policies including |
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scope and availability of services, location, hours |
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of operation and quality of care audit procedures |
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establishes and maintains collaborative relationships |
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with other health care providers in the service area |
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existence of a conflict of interest policy |
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The arrangements do not compromise the Board authorities or limit its legislative and regulatory role. Examples of compromising arrangements are: overriding approval or veto authority by another entity; dual majority requirements; super-majority requirements; or hiring and selection of the CEO.
YES ________ NO _________
STAFFING
The center directly employs the CFO, CMO and the core staff of full-time primary care providers.
YES ________ NO _________
If NO, the CEO of the center retains the authority to select and dismiss staff assigned to the center.
YES ________ NO _________ (Please cite reference document and page #.) ________________________________________
CONTRACTING
The center has justified the performance of the work by a third party.YES ________ NO _________
Written affiliation agreement(s) comply with current DHHS policies, i.e.:
YES ________ NO _________
- contains appropriate provisions around the activities to be performed, time, schedules, the policies and procedures to be followed in carrying out the agreement, and the maximum amount of money for which the grantee may become liable to the contractor under the agreement; _____________ ______
Organization: ________________________________ Grant # ________________
(where applicable)
Reference
Document Page #
- requires the contractor to maintain appropriate financial, program and property management systems and records
in accordance with 45 CFR Part 74 and provides the center, DHHS and the U.S. Comptroller General with access to such records; |
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requires the submission of financial and programmatic reports to the health center; |
______________ |
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complies with Federal procurement standards including conflict of interest standards; |
______________ |
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is subject to termination (with administrative, contractual and legal remedies) in the event of breach by the contractor. |
______________ |
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Signature of Governing Board Chairperson _____________________________________
Date ______________
PLEASE LIST ALL ATTACHMENTS
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