Operator:
Good day everyone and welcome to the Capitol
Associates/Rural Health Clinics (RHCs) Technical Assistance Conference
Call. Today's call is being recorded.
At this time, I would like to turn this call over
to Mr. (Bill Finerfrock). Please, go ahead sir.
(Bill Finerfrock):
Thank you, operator and thank you everybody for
participating in today's call. This is being done by the National
Association of Rural Health Clinics in conjunction with the Federal
Office of Rural Health Policy and we want to thank ORHP for their
support of this initiative. This is the -- I believe it's the sixth
call that we've done this year for the rural health community on
a variety of different topics.
All the calls are recorded and a transcript of
the call will be posted on the (ORHP) site in the next few weeks.
So that anyone who wished to go back and review something that was
said or communicated that is available. In addition, you should
have also received a link to the PowerPoint Presentations for our
speakers for today. Today they are available on the Website.
Today we're going to be talking about the National
Health Service Corps and site development and also the shortage
area designation opportunity for Rural Health Clinics to be designated
as a shortage area site under the designation process.
We have two speakers today; (Susan Salter) who
is the Chief of the Site Identification and Application Branch in
the Bureau of Health Professions and (Andy Jordan) who is the Chief
of the Shortage Designation Branch in the Bureau of Health Professions.
(Susan) is going to start off the presentation today and talk about
her work and how all clinics can work with her office. Then, (Andy)
is going to talk about what they do with RHCs and then we'll open
it up to questions from the audience.
So (Susan), the floor is your.
(Susan Salter):
OK and thank you very much and I want to thank
the National Association of Rural Health Clinics for inviting us
because these types of opportunities are really invaluable in our
outreach efforts. And I believe everyone has a copy of my presentation
and I'm just going to talk from that and kind of get through this
as quickly as I can so we can leave some time for questions.
The first slide I have is one that we really have
is our mission, the National Health Service Corps - Corps Mission
and I'd like to start any presentation on the Corps with our mission
because it's really what we're about. And that's -- we're committed
to improving the health of the nations underserved and we have a
lot of programs that help us do that. And that's the how -- the
reason that we do exist is to help communities to recruit health
professionals to improve the health of underserved communities.
So, the third site is onto recruitment and what
is it that we do? Well, we recruit clinicians and like I said we're
really looking for not just any clinician but clinicians who are
dedicated to working with underserved populations and vulnerable
populations. And so our recruitment messages are really geared around
that. It's not just we're looking for anyone. We're really looking
for that special clinician who wants to do this type of work.
And we do have a lot of recruitment activities
that we use to reach those folks and to drive them to the National
Health Service Corps to look for job opportunities and we have posters
that we do in and Residency Programs and videos; w. We have marketing
kits;. We do direct mail and print ads, presentations at meetings
and so we have a lot of activities going on to just try to reach
these folks to hopefully get them into our eligible sites.
The fourth slide talks about the programs that
I'm going to talk to you about today. That we have to help communities
and they include our Scholarship Program, our Loan Repayment Program--
((inaudible)) what I will do is I'll give you a brief overview of
those programs and than talk about eligibility for sites for those
programs and then how you would apply. And then briefly I'll go
over a couple of initiatives we have - our already a Responder Program,
I'll . Briefly, just touch on State Loan Repayment Programs that
we provide grants for; due to the National Health Service Corps.
Our Student and Resident Experience Programs that we have; talk
a little bit about that, and then our Campus Based Ambassador Program.
And then, in between that we'll talk about you
know, again, how your sites can apply to be National Health Service
Corps sites and what the criteria and qualifications are.
So, moving right along into our Scholarship Program;
what is the Scholarship Program? For those of you who never heard
of it, it provides Scholarship including, full tuition; it pays
tuition. It pays for books, expenses, fees. We give the Scholars
a stipend, a (site) for living and allowances and in exchange for
that Scholarship support they agree to serve in areas of greatest
need upon completion of their training and their service period
is from two to four years depending on the number of years of Scholarship,
of support that they received--get. The number of years they get
support for. So, one or two years of Scholarship support incurs
-- means they have a two year service commitment. Three years of
support is a three year commitment and four years of support is
a four year commitment.
The Scholars, when they complete their training,
assignment choose their practice sites from a list of sites that
we provide and those are sites that are in the neediest areas. To
give you some idea, we generally have about 200 Scholars that are
looking for jobs in any given cycle (, in any given year). So, we
don't have a whole lot of Scholars them and they do need to go to
areas of highest needs. So, we're going to talk a little bit later
about which sites would qualify for those Scholars
And then, the next slide covers the disciplines
that we offer Scholarships for. And they include certified nurse,
midwives, dentists, family nurse practitioners, physician assistants,
primary care physicians, in the primary care specialties of family
medicine, internal medicine, and pediatrics and OB/GYN. And we also
provide Scholarships for psychiatrists.
Our next slide briefly touches on our Loan Repayment
Program. Many more opportunities for Loan Repayment than we have
Scholars and the way that the loan Repayment program works is it
really recruits fully trained clinicians who have outstanding debts
from student loan and the Loan Repayment Program where we pay those
student Loans in exchange for a commitment to serve in an underserved
community. The initial commitment is for two years and they will
receive $50,000 that they must apply toward the outstanding balance
of their student Loan. If they don't owe 50,000 they get whatever
they owe. If they owe more than 50,000 they'll get the full 50,000.
That is tax exempt. And the program is a little different than the
Scholarship Program obviously, but one of the main differences is
that loan Repayors are clinicians who choose their job first and
then apply to the National Health Service Corps to get loan repayment.
So, whereas we have a population of Scholars that
are looking for jobs and we know who they are, loan re-payers are
really our broad recruitment of finding those clinicians who want
to do this and ensuring that high educational debt is not preventing
them from doing the type of work that they want to do.
So, our Web site, which I'm going to talk about
a little bit later, posts the jobs that qualify for our different
programs and so our recruitment efforts are really -- do you want
to do this type of work and don't let student loan repayment be
an issue for you. Here's all the jobs that will qualify for you
to apply to receive some loan repayment from the National Health
Service Corps.
So, it's very flexible, because clinicians don't
have to make the -- they don't make the commitment until they have
the job. They can apply while they're in final negotiations but
they don't have a commitment to the National Health Service Corps
and then have to find a job. They find the job first; and they can
already be working at the site work their three year and then apply
or they can apply and be improved before they even start work there.
So, the next slide lists the disciplines that
we offer Loan repayment for, which are broader than those disciplines
that we offer Scholarships for. It includes all of the same disciplines
that we offer Scholarships for but it also includes all primary
care nurse practitioners, not just family nurse practitioners,;
certified nurse, midwives, dentists, physician assistants. We also
do dental hygienists in the Loan Repayment Program.
And the next slide lists the mental and behavior
health professionals that we offer Loan re-payment for which, other
than psychiatrists, we do not offer scholarships for them.. So,
you can recruit different disciplines through the Loan Repayment
Program than you could through the Scholarship Program.
So, sites in the National Health Service Corps--;
what do they look like? Where are they? Well, they're all located
in federally designated health professional shortage areas or HPSAs.
They can be frontier. They can be rural. They can be inner city
urban. And they have to agree that they'll treat everyone regardless
of their ability to pay. So, they have to take away any financial
barriers to care for the populations that are located in their health
professional shortage area.
So, I'm going to just briefly touch on a couple
issues about HPSAs and (Andy's) going to give you a more in-depth
overview of the HPSAs process. But all of the sites in order to
qualify to be a placement site for the National Health Service Corps,
you have to be in a federally designated HPSA. And those HPSAs are
not designated by the National Health Service Corps. They're designated
by the Shortage Designation Branch and they have a Web site which
I've provided here for you which is very good. It provides a lot
of information on you know, the criteria for HPSAs; y. You can search
the HPSA database by state and county to see if your state or your
county has HPSA designations.
And if you really want information, though, about
applying for one or you have a question about whether you're in
a HPSA, you should contact your state primary care office (PCO).
They can provide you with the best information available on HPSAs
in the state. If you don't know who your primary care office contact
is you can call the National Health Service Corps's 1-800 number
which is the last slide of the presentation, . And you can ask the
person who answers that phone who your primary care office contact
is for your state and they can provide you with that information.
Or you can also link to it from the National Health Service Corps
Web site under our "Links" portion of our Web site.
So, moving on with HPSAs is -- HPSAs can be three
different types. Primary care which obviously there is a shortage
of primary care health professionals. There can be a shortage of
mental health professionals with the mental HPSA or shortage of
(oral) health providers for dental HPSA.
In the National Health Service Corps, clinicians
have to serve in HPSAs that are appropriate for their discipline;
so if your site is only located in a mental health HPSA, you wouldn't
qualify for primary care clinicians through the National Health
Service Corps programs. So, it's important to know about HPSAs and
know what HPSAs you have. It's also important to know your HPSA
score s Corps because all HPSAs are scored Corps and we're going
to talk a little bit about that in about one more slide.
Another -- a couple other things about HPSAs--
and I know (Andy's) going to really talk about this-- is all federally
qualified health centers and FQHC Look-A-likes have an automatic
HPSA designation. Certified rural health clinics are eligible for
the automatic HPSA but you do need to apply. And you need to meet
the National Health Service Corps charges for services requirements.
I'm going to talk a little bit about that.
So, when we talk about HPSAs being areas that
are designated as of having a shortage of health professionals,
they're often scored to determine the level of shortage. And so
they're scored from one to twenty-five. And you know, the lower
the score, the lower the need; the higher the score, the higher
the need. So, when we talk about scholars going to higher need areas
that would be those HPSAs that have a higher score.
So, that's how we determine the need in certain
areas and which sites will be eligible for which of our programs.
But, there are other programs that also use HPSA designation as
a criteria for n eligibility, criteria but it is definitely a main
criteria for the National Health Service Corps and we do use those
scores to determine the level of need and which NHSC programs the
site would be eligible for.
Now, getting into our charges for services, this
is a requirement for any site that wants to apply and be approved
as a National Health Service Corps site which means scholars or
loan repayors, depending on your HPSA score, could serve in your
site. And this is a requirement also if you would like to get the
automatic health professional shortage area designation if you're
a rural health clinic.
And the first thing that we need to do is that,
the fees for services need to be consistent with prevailing rates
in the area. And you have to discount or waive fees for individuals
at or below 200 percent of -- 200 percent of the federal poverty
level. So you have to -- for those folks that are 100 percent or
below the poverty level, apply a full discount and then a sliding
fee scale up to individuals who are at 200 percent of the poverty
level. And you have to accept assignments from Medicare and enter
into agreements with Medicaid and the CHIP programs for your state.
And you have to post the signage in a prominent place in the clinic
that tells patients that you do offer these discounts and that you
will not turn anyone away because of their ability to pay.
So, what type of sites do we have in the National
Health Service Corps? We have public sites. We have private practices.
We have community health centers. We have rural health clinics.
We have (Indian) Health Service. We also work with prisons. State
and Federal prisons do qualify for a health professional shortage
area facility designation. We work with community mental health
centers. So, we have a large array of sites that we work with.
And when we talk about eligibility, what type
of services do the sites need to provide? They need to provide comprehensive
primary care, primary mental health or substance abuse services
or dental services. So, we may have a dental clinic, a primary health
clinic or a mental/ behavioral health provider. The services have
to be ambulatory in nature. We do not do in-patient or hospital
sites. We -- really we're working with primary care out-patient
clinics.
And sites have to ensure access to ancillary services,
((inaudible)) in-patient and specialty referrals.
Now, when you're talking about applying for the
National Health Service Corp Loan Re-Payment Program, you have to
be in compliance at the time of the application. So, you can't say,
well, if we get a Scholar we'll implement a discount fee policy.
You have to have that in place and you have to be doing that in
order to be approved. So, at the time of application you have to
have those things in place. And you have to agree that you'll continue
to do that throughout the time that you have a National Health Service
Corps clinician serving.
And these requirements pertain to the entire site
and not just the NHSC(NHC) clinicians, so you couldn't say the NHSC
(NHC) clinician discounts their services -- their fees for service
-- but there are other clinicians in the practice that do not. And
another important thing to remember is that each location must apply
and be approved. A lot of times the site will get their main site
or their parent site or one of their sites approved and think that
Corps clinicians can just work at all their satellites. You really
need to have applications from every physical location and approve
those because health professional shortage areas do change in different
counties or different areas. And so we need to make sure that all
of those sites where the clinician would be serving do qualify.
So, that's an important piece to remember.
Male:
(Susan), on that point all the sites don't
have to qualify for one of them to qualify. In another words, a
site can still qualify individually. It's just the others don't
automatically get it as well.
(Susan Salter):
Correct. Correct. So, that's why we would
want all of those sites to apply so we can make sure they either
all qualify or just one or two qualify and then you know what's
eligible for National Health Service Corps.
So, our priority for funding; high need areas,
again higher scoring HPSAs receive priority for National Health
Service Corps. Scholars and they also receive priority funding for
the National Health Service Corps Loan Repayment Program. We talked
about the need as determined by the HPSA scores; the higher the
scores the higher the need.
So what does that mean? Well let's get into some
specific scores. When we talk about sites that qualify as placement
sites for National Health Service Corps Scholars -- just to remind
you that these are individuals who received Scholarship support
during their training and they already have a commitment and they
must serve at a site that we have approved. Now, just to let you
know that, again, we generally have maybe 200 or so scholars and
our law does--, our legislation does say that our list cannot be
more than two sites for every Scholar that we have in the placement
cycle, or. So who's looking to find a job to serve their commitment
that year. So as you can see we really have to limit the number
of sites that are on that list to the highest need areas.
And so the next slide talks about what those HPSA
scores are. So for fiscal year 2006 which began October 1, 2005,
a couple of months ago, the minimum HPSA scores, if you wanted to
recruit a primary care physician who was a National Health Service
Corps. Scholar, that minimum score s would be a primary care HPSA
of 14 or above. For physician assistants and nurse practitioners
it's a primary care HPSA of 13 or above, for certified nurse midwives
/midwife it's a primary care HPSA of eight or above and dentists
have to have a dental HPSA scores of 20 and above and psychiatrists
a mental health HPSA of 20 and above.
There are maximums to the number of new scholars
that you can get every year. You can get up to two new primary care
physicians who are National Health Service Corps Scholars serving
at your site. Now that is not affected by the number of scholars
you may have hired last year or you may have serving there. It's
also not affected by the number of loan repayors you have; so every
year you can get up to two new primary care physicians through the
NHSC Scholarship program. Up to a total of two new P.A.'s, nurse
practitioners or certified nurse /midwives whatever combination;
a maximum of two. No more than one psychiatrist and no more than
one dentist.
So some of you who maybe know your scores are
saying, "Wow those are high HPSA scores and we may not qualify"
and that's OK because we also have our Loan Repayment Program. Now
all approved sites that are in HPSAs are eligible for loan repayment
so there's no minimum score to be eligible for the loan repayment
program. However sites with a HPSA score of 14 or higher and that's
any type of HPSA (, any type of ((inaudible)) recruiting, primary
care, HPSA, mental health, HPSA or dental) HPSA do receive a priority
for funding which means that we can fund those applications from
clinicians ((inaudible)) who are serving in HPSAs that score 14
or higher at the time that they apply.
So, if they were to apply in January and their
application was complete and approvable and the site had applied
and was approved, we could approve them for loan repayment at that
time. Sites that have a score of 13 or below are funded after our
deadline for applications for the loan repayment program which is
the last Friday in March, and then they're funded by decreasing
HPSA score as funds remain available. And I can tell you in fiscal
years 2003, 2004 and 2005 that we funded all eligible and complete
loan repayment applications regardless of their score. So all the
way down to those that scored a zero were funded. Everyone that
applied and was eligible was funded. Those 14s and higher may have
got them earlier but everyone else also got them and all of those
awards are completed by September 30th but the majority of them
are completed by July or August of that year.
So it's important to know that even though we
have a high priority HPSA score for loan repayment every site is
eligible and it really depends on our funding levels. And we have
been very fortunate in these past three years to really have the
funds to be able to fund a lot of them. We also are able to apply
a large amount of our funds to the loan repayment program which
means we do less scholarships but we're able to do more loan repayment
and make more awards to folks who are either working in under served
areas or have an agreement to start working an under served area
during that year.
We also have maximum numbers of new loan re-payers
you can recruit. This is not affected by the loan re-payers that
you may already have serving or the scholars. And you can get up
to two new primary care physicians through our loan repayment program;
up to two psychiatrists, up to two other mental and behavioral health
professionals like social workers or clinical psychologists; , up
to two dentists, up to two dental hygienists; and up to a total
of two combination physician assistant, FNPs FMPs or other primary
care nurse practitioners and certified nurse /midwives. So you know
the opportunities for loan repayment are you know are there and
I just want to make it clear that all sites do qualify. And just
because you may not be in a 14 or higher that's no reason to think
that you're clinicians wouldn't be funded.
There's never a guarantee, however, for a number
of reasons. When that clinician applies there may be something that
makes them ineligible. Clinicians do have to be citizens of the
United States. They can't have an existing obligation for service
through some other Scholarship or loan repayment program. They can't
have defaulted on you know federal debt or --
so there's a
couple things that may make the individual ineligible, and of course
in the lower scoring HPSAs we may deplete our funds before we get
there. But like I said in the last three years we have been able
to fund all eligible applications.
So you're interested in this program and you've
been successful in recruiting a clinician. actually, and you're
successful. You applied, you were approved and you hire a National
Health Service Corps Clinician. Well, there's some things that you
need to understand before you even apply and, particularly, if you
hire a National Health Service Corps. Scholar or someone on your
staff receives National Health Service Corps. loan repayment. And
that is that, you must offer full time clinical positions and we
have a very strict definition for full time and it may not be the
same as what your site offers. Oh but our full time definition is
National Health Service Corps. clinicians must work a 40 hour week.
Of those 40 hours, 32 must be providing direct clinical services
in the outpatient clinic. Unless you are OB/GYN or an FSP that does
OB and then it's 21 hours in the outpatient clinic with the remaining
time spent you know providing services to the patients of the clinic
in the hospital. Bu but in any event, no more than 8 hours can be
done for administrative type activities. So it's important for you
to know that when you're interviewing National Health Service Corps.
clinicians or someone that you want to hire wants to apply for our
program.
You can't reduce the salary of National Health
Service Corps clinicians because they received a Scholarship or
will receive loan repayment. You must agree to tell us if there's
any changes in their employment status. If you're thinking of letting
them go, if you want to move them to another satellite site you
know we need to know those things so that we can have all of our
paperwork in order and ensure that they remain in compliance, and.
And that they get service credit because there are pretty stiff
penalties for National Health Service Corps clinicians who default.
And we want to make sure that that doesn't happen because they are
not in compliance.
And we ask that you only allow them to practice
at approved sites. Again, then if not they're out of compliance
and they get into a lot of trouble. We ask you to make available
personnel practice records, in particularly if you're going to let
someone go we really want to know why. You know that could impact
where we put them next, or if we put them someplace next, so we
ask you really to keep those lines of communication open with us
and that you allow us to communicate with our clinicians. They are
your employees but they also have a contract with the Federal government
and we do need to contact them from time to time to talk about their
contract and things that are going on.
So how do National Health Service Corps clinicians
find sites? If you apply and you're approved how would they find
out that you qualify for loan repayment? Well as I mentioned earlier
we do have national recruitment efforts and we get thousands of
calls to our call center and hits to our Web site and where we post
all of the jobs for sites that have been approved and have open
vacancies. So you can increase your chances of recruiting one of
the clinicians that we are recruiting by posting your vacancies
on our Web site and we also provide you an opportunity to provide
a site profile which would give more information about your practice
and about the position.
So how can you maximize your opportunities with
the National Health Service Corps? Well, first you need to apply
to be included on our opportunity list;, market your site;, recruit
potential loan re-payers, and, if you're eligible, recruit scholars.
So how do you apply to be included on the NHSC
opportunities list? And that's our next slide. You can download
our recruitment and retention assistance application otherwise known
as our R and R application on our Web site. And the Web site address
is there if you click on that, on the left hand side you will see
a list of tabs. One of them is "Applications" and if you
click on that you will see the recruitment and retention assistance
application for sites who want to apply. You fill out the application
and submit it to us. You can fax it to us. Again remember to do
it for all the sites that you have. Even if you don't have a vacancy
right now if you apply and are approved then it's much easier down
the road to post a vacancy or to add that as an assignment site
for a Corps clinician who is serving at your site.
We do ask that you keep your vacancies current
and you notify us if there's any changes to the vacancies because
the worst thing is someone keeps calling you and you keep getting
all these calls and you really don't have a job. It's a waste of
your time; it's a waste of the clinician's time that are coming
to our list. So and we want to keep that vacancy list as accurate
as possible so it has some credibility and people know that it's
a place to go to find current job openings that qualify for Corps
programs.
So our opportunities list is located on our Web
site-- again the left hand tabs--. There's a job opportunities tab.
Click on it and then from there clinicians can search the vacancies.
We post all open or unfilled vacancies on the Web site and you can
make changes to that by phone or email and our last slide does provide
that information for you.
Now you may request a vacancy for someone you
already hired and they're going to apply for loan repayment. We
do need you to request that vacancy but that clinician won't see
it on our Web site because it's not an opening vacancy. It's a filled
vacancy for which someone is going to be applying. Again you can
also do a site profile that can be downloaded along with the application.
You can fill it out and send it in with your application or you
can send it in later if you like.
Once approved you can post vacancies on our job
site. So like I said, you may not have a vacancy now but if you
get approved-in three to six months you may have a vacancy-then
. You can pick up the phone and call us and say, "You know
I want to post a physician family practice vacancy on the Web site."
And we can do it for you. You don't have to fill out the application
again. The applications are good for three years or until your HPSA
is de-designated or unless your site goes out of compliance, for
instance like you decide you're not going to have a discount fee((inaudible))
policy anymore. Then you, clearly, you know wouldn't be in compliance
with our requirements. But as long as you're still in a HPSA and
you're still in compliance your application is good for three years.
The application is very quick but I do ask that you read the last
two pages because those are all the agreements that you're making
when you sign that. So it's important that you understand them and
if you have any questions call our 1-800 number. I'll be happy to
go over those areas with you or answer any of your questions.
So when we talk about marketing your site-- again
developing and engaging NHSC site profile, developing your own Web
site, working with your primary care associations, primary care
offices, state offices of rural health, ((inaudible)) all of those
entities have --from most of them that I know -- of have recruitment
programs that they can also help you with. Target groups for direct
marketing, the NHSC site tool kit is a tool kit that we will send
to you if you're approved. You can also get it on our Web site.
It provides a lot of tools for recruitment activities and strategies
that you can implement. Quick things and ideas it's nothing you
know extraordinary but its things that you may not think about,
but they don't take a lot of time.
So when the National Health Service Corps works
with sites you really have a dual responsibility. And we ask that
you help keep our clinicians in compliance because again the financial
penalties for them are pretty high and we wouldn't want them to
be in a situation where they are not in compliance. So we ask that
they only serve in approved sites, that you do maintain a full time
clinical practice for them. Every six months a service verification
will come, comes to the clinician, they sign it, someone from the
site signs it, lists the number of days that they're away from the
site and it's faxed back into us. So it doesn't take a lot of time
to do that but these are things that we do need to keep those clinicians
in compliance.
So that talks about our Scholarship, our loan
repayment program, how you apply. It generally takes anywhere from
two to four weeks for an application to go through our review process
and be approved. It can take a little longer, it can take shorter
but in general we try to work it with those deadlines.
Male:
(Susan), just so you're aware of the time
we've got about 10 minutes before we would normally open it up.
I'm not sure how much time Andy needed but so that we have some
time for her too.
(Susan Salter):
OK is she here?
Male:
Yes.
(Susan Salter):
OK great. Well then I only have a couple
other slides and I just wanted to briefly go over that. Our Ready
Responder Program is another program we have. They are commissioned
officers in the Public Health Service. They serve an under served
communities with greatest needs. They're looking to put those in
folks in that are HPSAs that score of 15 or higher. They serve up
to three years. They also receive training to respond to regional
and national medical emergencies. So any site that's participating
in that program would have to provide coverage for those folks when
we needed to pull them out to respond; however, because they are
commissioned officers the National Health Service Corps would pay
their salaries. So if you're interested in that program you can
visit our Web site or call our 1-800 number and we can provide more
information.
The National Health Service Corps also provides
grant funds to states to operate their own state loan repayment
programs, eligibility and benefits do vary from state to state.
If you want more information on that you can call our 1-800 number
or visit our Web site, and. And we have contact information for
the states that received grants from us and participate in this
program. Some states have their own loan repayments programs without
grants from The National Health Service Corps., A and generally
your primary care office or your office or rural health would have
knowledge of those sites. We also have a campus-based Ambassador
program, which are faculty who volunteer to help the National Health
Service Corps recruit students into the mission of the National
Health Service Corps., and they are located on campuses across the
country, and we have a list of those folks on our Web site as well
under the Ambassador portion of our Web site. And they are always
looking for communities to hook up with to develop student or resident
opportunities in clinics. So, if you're interested in looking into
that more, you can contact an Ambassador in your state or contact
The National Health Service Corps directly, and we can help hook
you up with someone.
Our Student/ Resident Experiences And Rotations
in Community Health (SEARCH) orientations in community health also
is a contract that we have with, I think it's 23 or 25 states, to
provide student opportunities for students and residents. And if
you want more information on how you can become involved in that,
you can check our Web site to check the contact information for
your state or, again, call our 1-800 number.
Then National Health Service Corps also has technical
assistance that we provide to become a National Health Service Corps
site. You may never have had a discount fee policy Discount P Policy
or a sliding fee scale, and you're not sure how to develop one.
We can provide technical assistance to you on how to do that. We
can provide technical assistance to kind of help and develop those
academic and community partnerships that I talked about with our
campus based Ambassador programs. Recruitment/ retention of any
interested ((inaudible)) NHSC clinicians, we have technical assistance
for that. So, if you're interested in any technical assistance,
again, call our 1-800 number and you can ask for (Sharon Miller).
She coordinates our technical assistance requests. Or, you can talk
with your primary care office and they can contact us on your behalf.
And my last slide talks about our contact information, our toll-free
number and our Web site. And with that, I am going to turn it over
to (Andy).
(Andy Jordan):
OK. Sorry I was late.
Male:
That's alright. Go ahead, (Andy).
(Andy Jordan):
I don't have nearly as many slides as (Susan).
And I just go through some more general slides because it's impossible
to go into a lot of detail about designations and shortages in this
kind of format, really. So I'm just going to go through some things,
and maybe anticipate some questions based on the kind of calls that
we get. And then certainly, we'll try to respond to questions. There
are, for the rural health clinic audience, four different kinds
of designations these days that, you know, are relevant, in terms
of being eligible for the rural health clinic certification.
1) The health professional shortage area, which
(Susan) talked about for the NHSC eligibility, are also used for
this purpose.
2) Medically underserved area designations, which were primarily
used for eligibility for funding for community health center money,
are also used for rural health clinics.
3) The Governor's Certified Shortage Areas. There are some states
that have made extensive use of this kind of designation, which
is based on their own plan. And they can designate areas that don't
meet any of the other criteria. The state presents a plan, and it's
approved here; those areas are then eligible for rural health clinic
certification.
4) And then finally, there's the automatic facility HPSA, which
(Susan) talked about, and which we'll talk about a little bit more.
I describe that one as: it doesn't get you in the door, once you're
in the door, you're eligible for it, and it can get you other things.
But it can not get you in the door to be a rural health clinic or
to be eligible for that.
So let me go to the second slide - the table shows which ones are
used by CMS for rural health clinic certification.
So, if you hit any of those boxes, the area that
you're in could qualify, then you could qualify as a rural health
clinic under the CMS rules. Geographic and population HPSAs and
geographic MUAs, but not medically underserved populations, are
the way the rules are currently applied by CMS. Just real briefly,
the health professional shortage areas you might assume, based on
its name, is based primarily on the health professional shortage.
The number of providers now only counts physicians as compared to
the population in the area. What's the ratio? And there are some
high need factors that allow a little bit of adjustment. But it's
basically 1 to 3,500. One physician for 3500 people or 3,000 if
there's a high poverty rate, which is usually the thing that kicks
people into high-need. And we do have to look at areas around the
area you're looking at. Medically underserved areas are different.
It's a formula based with four different factors, and their weighted
values, the ratio being a part of the formula. But the other three
factors - poverty, infant mortality and population over 65 play
into the formula as well. So it's actually possible to have an area
where you don't have a shortage of primary care physicians at all,
but everything else is really high, and therefore, you can still
qualify. So the balance between those four makes a difference. There's
probably an 80-90 percent overlap between the two (HPSA and MUA)
roughly. But not all places are both.
We are actually in the process of developing a
new method which will combine both of them, officially. But right
now, they are different.
For the Governor's one I mentioned, the State
comes up with a plan. Most of these are in the mid-west and the
western states. The state presents a plan. And they often have cut-off
points that are lower than what we use for the HPSAs, in terms of
a ratio. But they've justified it based on the unique characteristics
of their state, which often have to do with low density, long distances
and things like that. I don't know what the total number of states
is that use this process. It's maybe 10 or 15 that uses it fairly
actively to get areas certified. And a little description of how
it goes - it would have to come from the Governor, or the Governor's
Delegate.
The next slide - let's talk about the important
reminder at the top. Now this is one of the things that comes up
most often here. It's a three year rule for CMS in terms of the
status of the designation. Some years ago when they put together
regulations, unfortunately, they got bad information or mistook
information that was given to them by this office at the time. And
they put the three year time frame into their regulation. But unfortunately
it doesn't match our time frame. We basically update HPSAs after
they've completed three full years. Which means the update isn't
started until the fourth year, and often isn't finished until the
fifth. So our cycle is more like a four- to five-year cycle. Theirs
is a three-year cycle, which causes problems.
And we've told them about this, but they keep
telling us to adjust our schedule as opposed to them adjusting theirs.
We told them, if you want to do that, go ahead and give us the money
to do the work, and we'll be happy to do that. But we didn't really
say that. So it is very important for rural health clinics to pay
attention to the dates on the designations and if it's within a
three year time frame, even though it may not be due to us to update
it, it may be looked at by them as a deadline. My conversations,
and Bill, you can confirm this information, I think you know about
this. For a new rural health clinic, they are applying the three
year rule. I just had one come up in South Carolina and there was
a question whether they did three years as of the day, or three
years as of the calendar year. But, they are applying it for a new
rural health clinic. For rural health clinics that are in a HPSA
or an (MUA), that hasn't been updated within three years, they aren't
necessarily pulling the rug out from under people.
(Bob):
That's correct.
(Andy Jordan):
Because it requires regulations, and we know how
long those take to write. So, it's particularly important for new
applicants for rural health clinics that HPSA has to be updated
within three years. The (MUA) designations do not require any updates
by us. The regulations that they're done under don't have an update
cycle. But for this purpose, if you happen to be in one and that's
the only thing that makes you eligible, it's going to have to be
updated. So we've talked with our state contacts. They're aware
of this three-year deadline. We've talked to the Office of Rural
Health Policy about it, trying to figure out ways to make sure -
so that nobody gets caught short. Now the good news is, they're
not pulling the rug out from under you, it's not as bad as it could
be. But we are concerned that there's a miss-match between our process
and there's. You can get information from our Website. The information
access that (Susan) shared about that gives the dates when the last
update was done, and that's the date that triggers the three year
factor. If you use the advance search capability on our Website,
which is significantly better than the last one, you can find that
information. We put the information here on the slide also, how
you find out who the PCO - the primary care office - which is a
state office that (Susan) referred to somewhat - who does a lot
of designation work with us. Those are key people to know.
The automatic facility HPSA is part of the Healthcare
Safety-Net Amendment of 2002. There was a provision to kind of automatically
certify certain kinds of safety net providers as HPSAs. Community
health centers, federally qualified health center look-alikes, are
basically automatically covered because - in order to meet the requirements
to be funded or to be a look-alike, they have to be providing services
to people regardless of ability to pay. Rural health clinics were
added with the provision that they had to demonstrate that they
did serve people regardless of ability to pay because rural health
clinics aren't required to do that under the basic program. So we
had to put in a two step phase for that.
What we did was develop a letter with a form that
basically captures all the information that (Susan) has shared with
you in terms of the charges for services requirements of the National
Health Service Corps. And we sent that out. The first mailing we
did, to probably about 3,000 or however many rural health clinics
there were at the time - sent that information out to them and said
send this form back in if you want to pursue this. We have approximately
600 that we have received that are on our active list. Now, why
do you want to do this, or should you bother depends a lot on your
circumstances and there may be no reason to do it. If you're a rural
health clinic because you're in a HPSA, you don't need to do it.
You're already in HPSA. So, if you want recruitment assistance from
(Susan), you can get it. Because you're already in a HPSA, you don't
need to do this. If you're in an (MUA), and that's how you get into
the rural health clinic program - but you want recruitment assistance,
then this becomes useful because (MUA) doesn't get you a National
Health Service Corps person. So that might be one reason to do it.
Same thing is if you're in a Governor certified area, to get rural
health clinic certification, if you're not into HPSA, you could
use this to get National Health Service Corps recruitment assistance.
And there may be some other programs. The J1 Visa program operates
the same way; if you have the automatic HPSA, and it didn't recognize
one of your other ones, if it didn't recognize your Governors' one,
then you might be able to use it. So for a lot of you, there might
be no reason to do this, because you're already in a HPSA. And you're
done. And you will have a higher score, in most cases, from the
area HPSA or the population HPSA that you're in than you would if
you got a facility HPSA. And from our conversations with CMS, and
again, not all of this is completely finished yet, if for example,
you were in a regular geographic HPSA, so, you're in Jones County,
Nebraska. And Jones County, Nebraska is a HPSA. And because it was
a HPSA, you became a rural health clinic. Jones County Nebraska
then loses it's HPSA designation because it no longer qualifies.
You got a couple more docs in there, it doesn't meet the ratio,
and we would just basically take it off our list of HPSAs. If you
had an automatic facility HPSA, from what they have told us, that
would not keep your rural health clinic eligibility because it's
based on the geographic HPSA and not the automatic facility HPSA.
Now, none of this has ever come out in writing, as far as I know.
But the conversations that people have had indicate that the automatic
HPSA would not save you from losing the eligibility.
(Bob):
Not at this time. And there's some new rules that
are going to come out in the Spring. And that may be revisited at
that point.
(Andy Jordan):
Right. So a lot of these things are very dynamic
over the last few years. So, that's where it stands right now anyway.
So, the other challenge we have in keeping up with this one is,
you know, keeping up on an updated list of what rural health clinics
are. They come and they go all the time. So we now have, with the
(HRSA) warehouse actually, finally having a relationship with CMS
to get the data. We are now getting a quarterly list from CMS of
the rural health clinics. And we're trying to keep up with updating
our information with that. Now, we are not doing mailings at this
point to new sites that show up. We've been working with (Bill)
and the other rural health people to try and makes sure that information
gets out. And the states are certainly on top of that. But we just
can't do mailings every quarter for everybody that gets added. And
if there are other creative ways we can try and get the information
out, we'd be happy to do it. But we have about 600 that have come
in with the forms filled out, saying, yes, we do meet these requirements.
We have a sliding fee scale. We've developed one for this. And it
meets the requirements. We have talked to CMS about including this
information in their monitoring or survey and certification that
they do over time. We haven't had many detailed conversations in
while. But the expectation is, you sign that form, you said you'd
do it, you'd better do it because if anybody ever comes and asks
and you're not doing it--it won't bode well for you.
(Bob):
\We're going to need to start wrapping up here,
for your part of it. So we can open up for some questions that people
might
(Andy Jordan):
Yes. The only other thing I would say in terms
of the score, because (Susan) mentioned the score is important--when
we have automatic designations obviously we don't get data with
them, and the score is based on data. So what we did with the automatics
was pull the others from national data, which is basically, in most
cases, county level data on poverty, for ratios, and other things
and produce a score that way. Most of which, given the data, were
very low. You know, zero, one, two, three, four. So for the Scholarship
program, these numbers aren't going to help you much there. But
for loan payment it wouldn't be a barrier. If people submit data,
we can add that to the process to have a score to reflect the reality
where you are. But, we didn't have any other way to do it--an across
the board kind of update. So the score could be an issue. Again,
the best thing to do would be to talk to the people at the state
and the PCOs about it. Because they understand what was done and
what can be done to maybe change some of those score if that's an
issue for you. So that's pretty much the issues from our standpoint
in terms of rural health clinics, other than you know, whatever
questions you might have.
(Bob):
Thank you, (Susan). Thank you, (Andy). What we're
going to do now, is open the lines up for questions. When we do
that, the operator will come on and give you the instructions. I'd
like to take--we had a question that was submitted in advance through
an e-mail that I'd like to pose to you. And it's from a (Tammy Vogelar)
"Looking into becoming a National Health Service Corps site.
And on the application it talks about the office not discriminating
in the provision of services to individuals. And it says the healthcare
services we have to provide either at no charge, nominal charge,
sliding fee scale, for patients whose incomes are at or below 200
percent. How can we know how much the patients income is? No one
is going to be carrying it around them, or the staff have the time
to figure it out. And how can an office do this?" Do you have
suggestions for how folks can verify the individual's eligibility
for a sliding fee scale? Do they just take their word for it? Do
they have to provide documentation? Do they need to provide documentation
each time they come in to the clinic? How do they handle that?
(Susan Salter):
OK. That's a good question. And I'm going
to answer it slowly. The Corps does not tell you how you have to
do these things. But, as a rural health clinic, as we're a Federal
health clinic, you would have to establish a policy on how you will
do it and apply that policy for every individual that applies for
a waiver or discount of fees. Now, I do have some materials that
I can provide on how you do that. And we do have technical assistance
that we can do. We can even do another call at sometime, on technical
assistance and how to develop and implement a discount fee policy.
But we don't particularly say--some people, you
know, want a lot of information. Some people just take it on word.
Some sites, some people just know what's going on in their small
community. And who's having trouble. Some people request it every
time the person comes in. Others do it on a yearly basis. We like
to see something that's not burdensome. So, if you're requesting
so much information that that's going to be a barrier to someone
even applying for it --because you want so much information, that
they can't provide it -- . Then that's a barrier. But, you know,
some people want tax records, some sites accept a pay-stub, some
sites just take it on their word. So, we can provide you with some
further technical assistance. I don't think there's one particular
way to do it. And I've seen it done many different ways.
(Bob):
OK. If you have any written materials, we'd be
happy to distribute those through the list serve to folks. And then
perhaps Tammy could contact you directly at the number that you
provided if she wanted to follow up with you individually. But I
think the key here, and what I've heard, and what I've tried to
stress to people is, whatever policy you have, it does have to be
universally applied. It cannot be Ad-Hock in nature. Is that correct?
(Susan Salter):
Correct.
(Bob):
So you can't just sit there and go, well, Mrs.
Jones is nice and I know she's having a little bit of trouble. I'm
just going to take her word for it, that she's low income. But Mrs.
Smith, the next patient--gee, you know, I don't think she's as bad
off as she says. I'm going to ask her for documentation and a copy
of her tax return.
(Susan Salter):
Correct. It has to be consistently applied
to everyone. So you have to have a written policy. And you know,
we can also provide, not only technical assistance to develop it,
but also to train your front-office staff on how to do it, as well.
(Bob):
Operator? You want to open the lines up?
Operator:
Thank you. The question and answer session will
be operated electronically. If you would like to ask a question,
please press star-one on your telephone key pad. A voice prompt
on your phone line will indicate when your line is open to ask a
question. Please state your name before posing your question.
(Bob): If you would also state where you're
from, too.
Operator:
Once again, that is star one if you would like
to ask a question and we'll pause for a moment.
Again, that is star one. If you are using a speakerphone
please make sure the mute function is turned off to allow your signal
to reach the equipment.
Male:
If we're not getting any questions, I have
some others operator.
Operator:
We have no phone questions at this time.
Male:
OK. On the Corps, you indicate that you
do recruit a variety of mental health professionals under the loan
repayment program but I want to make sure I heard correctly that
under the Scholarship it is only psychiatrists that you recruit
for the Scholarship program?
(Susan):
That's correct.
Male:
Is that because of the way the statute is
written?
(Susan):
Well, we're doing - you
know, as we look at our funding and we do have a push to get more
individuals out into service as quickly as possible, we're actually
doing less scholarships and more loan repayment.
Male: OK.
(Susan):
And we have never not awarded
scholarships for the mental and behavioral health disciplines other
than psychiatry and so, because we're doing less scholarships and
more loan repayment, we seem to be doing a good job of recruiting
those disciplines through our loan repayment program. So, because
we're not looking to expand the Scholarship program at this time,
we haven't added any new disciplines to that program.
Male:
Are you still statutorily mandated to set
aside a certain percentage of scholarships for PAs and nurse practitioners?
(Susan):
Not for the Scholarship
program. We have to do an overall but that can include loan Repayment.
Male:
As well as scholarships? And I know at one
time you were having some difficulty finding some places for (folks).
Is that still the case?
(Susan):
We do pretty well at this
point. I think nurse midwives, you know, we still have - when we
had the requirement that we did a certain number of scholarships
for new nurse midwives, FNPs and PAs, and because the training program
is, you know, shorter than the physicians with medical school and
residency, and we have a lot of PAs, NPs and CNMs coming out into
the placement cycle quicker and we were giving a lot of awards.
So now that we haven't had to do that in the last couple of years,
we seem to have a manageable number coming out although we do still
struggle with the appropriate practices for a newly trained certified
nurse midwife that's just . That's just coming out without experience
so we are looking if you have a need for that discipline. And that's
why the scores - you'll see the HPSA scores is only an eight for
that particular discipline. But for PAs and FNPs it is at a 13 so
we're doing pretty well with requests for those disciplines now.
Male:
Operator, have we gotten in any phone calls
questions?
Operator:
We do have one question.
Male:
OK.
(Mary Sheridan):
Hello?
Male:
Hello.
(Mary Sheridan):
Hi. I'm wondering if you could talk about the
reports.
Male:
Can you give us your name and where you're
from?
(Mary Sheridan):
Oh, sorry about that. This is (Mary Sheridan)
from the State Office of Rural Health in Idaho. I was wondering
if (Susan) could talk about the reporting requirements for sites
that receive Corps resources?
(Susan Salter):
You're talking about the Uniform Data System
reports?
(Mary Sheridan):
Yes.
(Susan Salter):
OK. The Corps does have a reporting requirement
for sites. It's called our Uniform Data System Reporting and if
you are a federally qualified health center (or) receive grant funds
through the Bureau of Primary Health Care you actually submit a
UDS report to the Bureau of Primary Health Care. If you're not,
then you would be required to submit this data to the National Health
Service Corps. Now we do offer training and we will pay for travel
for one of a staff person who's going to fill out these reports
to come and get training. We provide internet training, we have
CDs, but it's basically a reporting of information related to the
practice, to the patients that you're treating and the services
you're providing. And it does require that the data be collected
so you can report on it. You only have to report on it if you have
a clinician who serves during, you know, in your clinic during a
certain period of the year. So if you're just applying and you don't
have anyone, then you don't do the report. But once you have a clinician
serving you are required to provide that report. And we do offer
a lot of assistance to help you fill out that report. Our Web site
does have information on that so it's a good thing, you know, to
go and check into that and see what type of information we'll be
asking for.
(Mary Sheridan):
Thank you.
Male:
Thanks, (Mary).
Operator:
And there are no further phone questions at this
time.
Male:
Well I think that does it for me. I think
we're probably up on our hour anyway, so I want to thank both (Susan)
and (Andy), the National Health Service Corps and the Office of
Shortage(Sureties) Designation respectively for spending some time
with us this afternoon. I want to thank all of our participants.
As I mentioned earlier, this series is sponsored by the Office of
Rural Health Policy and run by the National Association for Rural
Health Clinics and we want to thank ORHP for their support of this
initiative. There will be a transcript of this call posted on the
ORHP Web site in a couple of weeks and in addition, if you have
not, please go to the Web site and download the slides for our speakers.
And I want to thank everyone for your participation. Our next call
will probably be next month and we're looking at holding it on the
Medicare advantage and requirements and negotiations with rural
health clinics under the new Medicare Advantage Plan. Thank you
all for participating and we'll see you next month.
Operator:
And that does conclude today's conference. We
do thank everyone for their participation.
END
|