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Moderator: (Bill Finerfrock)
May 10, 2006
2:00 p.m. CT

Operator:

Good day everyone and welcome to the RHC Technical Assistance Conference Call. As a reminder, today's call is being recorded.

At this time, I'd like to turn the call over to your host, Mr. (Bill Finerfrock). Please go ahead, sir.

(Bill Finerfrock):

Thank you, operator. And I want to thank all of our participants today and welcome you to the 9th call on the Rural Health Clinic Technical Assistance conference call series. Today's call is on Rural Health Clinics, the (basics). This is part one of a two-part presentation we'll be doing. The next call, the second part of this, will be May 24th at 3:00 Eastern Time.

Today's call is going to cover Rural Health Clinic and location issues and the next call will cover Rural Health Clinic operational issues. I will, in addition to being your moderator, I'm also going to be the speaker in today's program, which is scheduled to last one hour. I'll do about a 45 minute presentation and then open it up for the last 15 minutes for questions and answers.

This series is sponsored by the Health Resources and Services Administration Federal Office of) Rural Health Policy in conjunction with the National Association of Rural Health Clinics, and the purpose is to provide Rural Health Clinics staff with technical assistance, RHC specific information. This series began in 2005 and is currently slated to run through the end of the current fiscal year. We are hopeful that it will continue beyond this year. There is no charge, as you know, to participate and we encourage you to let others know about this series and what we're trying to accomplish here.

On your first slide, you will find my contact information at the National Association, my phone number and my e-mail. And I hope you'll take the opportunity to contact me if you have any questions. I would also encourage you to take the opportunity to download a copy of a book that we produced on behalf of the Federal Office of Rural Health Policy. It's called 'Starting a Rural Health Clinic: A How-To Manual" and that's available on our website and that goes through many of the issues that you may have questions about. Some of the things that I'm going to talk about today, we'll have a full listing of all of the information on shortage area designations for Health Professional Shortage Areas, medically underserved areas, contact information, a sample policy and procedures manual, a sample cost report, as well as other information that you might find helpful. And as I said, that is all available and you're provided a link in the slides for today's call.

The Rural Health Clinics program is intended to provide and improve access to care in under-served, rural areas. And they have very specific definitions- the laws and the regulations have very specific definitions of what it means to be both in an under-served area as well as a rural area. And we're going to go over those requirements today. In addition, those designations must be what are considered current. A Rural Health Clinic must be located in an area that is currently designated as underserved and an area that is not an urbanized area.

For purposes of the Rural Health Clinic program, that word current, is defined as not more than three years old. So that a Rural Health Clinic needs to be located in an area with a shortage area designation that is not more than three years old. Now, for those of you who are existing Rural Health Clinics, I don't want you to run out and get scared that you're going to get kicked out of the program. The current application of this requirement is only being set for new clinics. A new clinic that wants to come into the program must be able to demonstrate that the shortage area designation that they're using is not more than three years old. There's currently no process in place for decertifying or dealing with clinics that have designations that may be more than three years old, although I will say at some point, that could become an issue. But as it stands now, if you want to come into the Rural Health Clinics program as a new facility or a new clinic, you must be in a shortage area that is less than three years old.

You must be in a non-urbanized area. Now, for purposes of our program, what this means is that the definition is you are defined by what you're not rather than by what you are. The federal census bureau maintains the designations of urbanized areas, so any community that is not an urbanized area is eligible for Rural Health Clinic designation. Essentially to be an urbanized area, it's any community of 50,000 or more or contiguous communities whose combined populations exceed 50,000. So if you're not in an urbanized area, you meet the definition of rural for purposes of participation in the Rural Health Clinics program.

Now, those designations change. They change with every decennial Census and they may periodically change in the intervening ten years because communities will seek to have their community reclassified. Based on the 2000 Census, we saw a number of areas and boundaries change on urbanized areas in the United States because many local government officials were very interested in having their communities incorporated into a urbanized area because of the availability of transportation dollars, urban community development dollars, the environmental protection dollars that were only available in urbanized areas and many of those town fathers sought those changes without realizing the impact it could have on health care in their communities.

Now a lot of folks don't know whether they're in an urbanized area, how do you find out if you're in an urbanized area? And what I've provided you with in the slides is, under- you'll see it starts out 'how do I find out if my community is in an urbanized and underserved and an urbanized area?' And first, what we're going to go through is how you can find out if your community is in an urbanized area or a non-urbanized area. You'll need to contact the Census Bureau- and this can be done online. And what I've provided you with there is a link to the appropriate section of the Census Bureau's website that will take you to the area of their site that deals with urban and rural classification.

You'll see at the top of that page, if you go to that link, it'll say 'Census 2000 Urban and Rural Classification.' And it goes through, at the top of the page, some narrative about describing what that means. If you scroll down the page, you will see a header that says, 'Locating Urbanized Areas and Urban Cluster Boundaries.'

Now, I want to stop here for a second and make a clarification because there's been confusion out there over the term 'urban cluster.' Urban cluster is a new term that is new to the Census Bureau. All urbanized areas are part of an urban cluster, but not everywhere within the urban cluster is it part of an urbanized area. So I've been contacted by communities- clinics in communities that tell me, "Well, we were recently told that we're now part of an urban cluster. Does that mean we lose our Rural Health Clinic designation?" Well, it doesn't necessarily mean it's going to be in jeopardy. It could be that you're part of the urban cluster that's not part of the urbanized area. The statute is very specific. You must be part of an urbanized area. So if someone says, "Well, you're in an urban cluster," that doesn't necessarily mean there's anything you have to worry about. You only need to worry if somehow you're in an urbanize area.

I will say that based on our current estimates; there are about 120 Rural Health Clinics that are currently in areas that are now defined as urbanized areas. These are communities where either the population has grown since the clinic was started, maybe in some cases 20 years ago, where it was a community of 35,000 people to where now the community has a population that exceeds the 50,000 threshold or a community that has been absorbed into an urbanize area for a larger, contiguous community and they now find themselves as part of an urbanized area. Those clinics may be in jeopardy of losing their Rural Health Clinic designation because they are now part of an urbanized area.

But let's go through this. So then you can locate your urbanized area. You'll see a link under there that says 'Urbanized Area and Urban Cluster Boundaries.' Then there's another link that you can go to which also will take you to urbanized areas, the web page. And on the left hand page there, you will see the word 'maps' and if you go to that and you click on that, you'll see that there is a sub-header category in there called 'Reference Maps.' And you go to that- that section and that will take you to a page that will allow you to identify which state you want to have a map for and you can just identify- now, for purposes of our discussion today, what I showed you in the slides is the national map. You can also get a national map and just click on the state that you want. But for purposes of our presentation, I chose the state of North Dakota. So what you see there is the map that you would see if you went to that page, the map page, and it shows you the area of North Dakota.

You can then burrow down- you'll see across the top, there's an opportunity to make the map smaller, to get a closer view of what's going on in that area or a larger view. You can go out to the United States or you could go down literally to the block level on that mapping program and see exactly where the boundaries may exist. So in our particular map here, I burrowed down and you know, you can, as I said, literally see where the boundary line for that urbanized area in North Dakota occurs. It's literally- in the one corner there, what I tried to demonstrate- and this is the Fargo area, the Fargo urbanized area of North Dakota.

Twelfth Avenue, you'll see there that the boundary line literally runs along 12th Avenue in Fargo and at one point, the north side of 12th Avenue is not part of the urbanized area but the south side of 12th Avenue is. And so you can literally get down to this block level of determination and so if you were to establish a Rural Health Clinic, and in this particular situation you were outside of that urbanized area, you would be OK. But if you were literally on the other side of the street, you wouldn't. And we do have some situations where this very specific type of arrangement has occurred where the boundary line goes right down the middle of the street and you have a facility on one side of the street that's considered urban and you have a facility on the other side of the street that's considered rural for purposes of the Medicare program.

You can also- in the next slide, I provided you with a link- you can also find information if you just want to go through and see the names of the urbanize area, it can provide you with an alphabetically sorted list of urban areas and urban clusters. And you can break that down by state. When I queried that on North Dakota, there are three designated urban areas in North Dakota- Bismarck, Fargo and Grand Forks. And again, you can go to the map and burrow down- burrow each one of those down to the block level.

I would encourage you to go and take a look at the Census Bureau's website, try and become familiar. Determine whether or not you are in jeopardy or anywhere close to an urbanized area so that at some point, whether or not it's something you need to be aware of and cognizant of.

The next issue is that you must also be a shortage area, and there are three types of shortage area designations that area available under the Rural Health Clinics program. You have to be in a health professional shortage area or a medically under-served area or an area designated by your governor as under-served for purposes of participating in the Rural Health Clinics program. And again, this is the area where the "currently" designation criteria comes into play.

What I'm going to do is go through the general criteria for each of the shortage area designations because very often folks are the in the program and they may not even realize why they're a shortage area, what exists, whether it's a medical under-served area, health professional shortage area. And I think it's important that you appreciate and understand what it is that allows you to have that Rural Health Clinic designation.

Under the Health Professional Shortage Area designation process, or sometimes referred to as a HPSA, the acronym, an area can be either geographic health professional shortage or a population health professional shortage area. But geographic, what that means is that as a defined geographic boundary that- that looks at availability of health care within that defined geographic area for all people who live within that geographic boundary. A population health professional shortage area also has a defined geographic area, but it only makes the determination for whether or not there's a shortage area for a particular or finite population within that geographic area, and I'll get into that in a little bit.

So for a geographic area, what it stipulates is that a geographic area will be designated as having a shortage of primary care, medical care professionals if the following three criteria are met: the area must be a rational, what is referred to as a rational area for the delivery of primary medical care, and one of the following conditions prevails within that area- there is a population to full-time equivalent primary physician ratio of 3500 people for every primary care full-time equivalent physician or the area has a population to full-time equivalent ration less than 3500 to 1 but greater than 3000 and has unusually high needs for primary care services or insufficient capacity in existing primary care providers; and three, the primary care professionals in contiguous areas are over-utilized, excessively distant or inaccessible to the population in the area.

Now, one of the questions- there are obviously several questions that can arise in the context of that definition. First of all, what is a rational service area? Rational service area can be a full county, it can be part of a county, it can be parts of multiple counties that may overlap. What they're looking for, as it's says in the requirements, "is a county or group of contiguous counties whose population centers are within 30 minutes travel time and the following areas will be considered rational areas for the delivery of primary care: a portion of a county or an area made up of portions of more than one county whose population, because of topography, market or transportation patterns, distinctive population characteristics or other factors, has limited access to contiguous area resources as measured generally by a travel time of greater than 30 minutes to each resource.

What they're looking for here is not something that is necessarily a politically gerrymandered group of communities, but a community is where you can make a rational argument that these really should be considered as part of a whole. We have, you know, a town of 5000 here and another town that's 15 miles away of 5000, and we should be considered as a combined entity for purposes of this because there's a lot of commerce. We have a grocery store; they don't have one in the other town. They have a hardware store or we have a pharmacy; they don't. And show that there's commerce and there's activity but it is a rational boundary that you're determining to bring those communities together for purposes of looking at what is the availability of primary care in that area.

Now you must- if you look at in- you can look at it in an urban area, too, which is not part of ours but you can look at a subset within an urban environment. Established neighborhoods or communities within a metropolitan area, which display a strong self-identity within some cities. You know, you'll hear people talk about, 'well, I'm going down to Chinatown' within a particular city. Or I'm going to the west side. You know, whatever designation they may have because it becomes an identified subset within the city, they can be looked at as their own subset of populations. Obviously, that doesn't apply here because those are metropolitan. But I just wanted to point that out.

With regard to the distance, it's referred to, as I mentioned, in time, 30 minutes travel time. And as we all know, 30 minutes travel time can mean very different things to people, depending upon the part of the country that you're in. In rural communities, 30 minutes can sometimes be 30 miles. In an urban area- I'm currently in Washington, DC. This morning- my house is 15 minutes from my office, and this morning it took me an hour and 30 minutes to drive to my office. So 15 miles equates to 90 minutes sometimes in an urban environment.

So how do we convert that time factor into a mileage component? And what the rules provide is that under normal conditions- obviously, we could discuss what's normal. What's normal in Alaska may be 10 feet of snow and what's normal in Florida may be something different. But under normal conditions, what are referred to as primary roads, 20 miles. And so, that would be your distance criteria there. If it's mountainous terrain or in areas with only secondary roads available, that 30 minutes equates to 15 miles. And if it's in flat terrain or an area that's connected by an interstate highway, it would be 25 miles. So the standards provide flexibility to translate your 30 minutes into a mileage criteria that seems to be appropriate and relevant for the geographic situation in your particular area.

So now what do we do in terms of how do we know- once we've defined our area, how do we count the people that exist within that area? And the first thing we look at is what would be, obviously, is the population count would be used, would be the total permanent resident civilian population of the area. But we do exclude inmates of institutions with the following adjustments were appropriate. And by inmates of institutions, we're referring to those who are not at the institution by their own accord or rather because state has decided that they needed to be separated from the rest of society for some period of time.

So first we look at the- the permanent resident civilian population, which you can get from probably your local officials, county or state officials. Then we would look at seasonal residents, and this can be very important in some rural areas of the United States where you have a significant influx of population during particular seasons of the year. In some of the mountainous areas where you have skiing, et cetera, you may see, you know, in some cases, a doubling or a tripling of a population during a three or four month period of the year. Those individuals, those seasonal residents, can be counted and there's a mechanism. Seasonal residents are defined as those who maintain a residence in the area but inhabit it for only two to eight months per year. They may be included in your count, but they have to be weighted and proportioned to the fraction of the year they are present in the area. So if a person lives there for six months, instead of being counted as a full person, they would be counted as a half person.

So if you had 3000 individuals who were half year residents of your area, they would actually be- for purposes of this count- be counted as 1500 residents of that area.

Tourists, who are those who are there for even shorter stay- but again, who may place demands on the health care system during the time that they're there- can also be counted. And there's formula for counting in tourists and who a tourist may be. I know that, for example, out in South Dakota, you know, people will go out to see Mount Rushmore or they'll go out to see the geysers. They go to see the national parks. There's a town there called Wall, South Dakota that's, you know, famous as a tourist end spot. How do we count those? They may come off of a trail and make demands on the health care delivery system. So tourists may be included in the area's population and they are weighted at a .25 using the formula that's on the slide there. So don't forget to add tourists to your count, as well.

And then the last group that we can add to your permanent resident population are migratory workers. And again, this is a significant population in some rural communities. I was recently out in Washington state speaking to the Rural Health Clinics there and they have a large migrant population because of the wine and fruit industry that they have there. But migratory workers and their families may be included in an area's population using a formula where it's a fraction of the year the migrants are present times the average number of daily- daily number of migrants during a portion of the year that migrants are present. So very similar to those who are seasonal residents of your community, the migrant worker would be considered a seasonal resident of the community and it can be counted into the total population.

Next, we would take a look at what is the primary care provider compliment for your community? Now here, the government only looks at primary care physicians. We do not currently count physician assistants or nurse practitioners or nurse midwives in our primary care to population ratio. There has been discussion over the years of adding that to the formula, but they are currently not part of the formula. We only look at what the federal government refers to as a primary care physician which, for purposes of this discussion, they would be considered a general practice physician, a family practice physician, general internal medicine, pediatrics or OB/GYN. Those are the primary care specialty physicians that would be counted as far as your physician population.

If you have a psychiatrist, if you have a surgeon, if you have an orthopedist, if you have an emergency room physician, they do not get counted. They only count those professions, those specialties that I've identified. And if the- if there are physicians who are solely engaged in administration, research or teaching, they would not be included. So even though they may have the appropriate credentials as far as their specialty, if they are not involved in the delivery of care to patients but solely involved in administration, research or teaching, they would be excluded from your count- in counting your primary care physicians.

In addition, there is a mechanism, if you had interns or residents for some reason in your community, they would be counted at a .1 full-time, equivalent to a physician. If your physicians are graduates of foreign medical schools and not citizens or lawful permanent residents in the United States, those physicians would not be included in the count, as well as if the physician is a graduate of a foreign. medical school who is a citizen or lawful permanent resident but does not have an unrestricted license, they would be counted as a .5 (FTE).

So all of those things get factored into how you identify your primary care physician. And as we go through, then if there are physicians who are there who are semi-retired, who operate on a reduced practice schedule due to infirmity or whatever reason, you would make an adjustment to the physician's (FTE) for that. The full (FTE) is a primary care physician who works a 40 hour week is the standard for determining the (FTE). If your primary care physician works less than a 40 hour week, every four hours spent providing care is accounted for as .1. So if the physician spends 20 hours a week providing primary care in the actual delivery of care, then that physician would be counted as a .5 (FTE). Even though they may be there 100% of the time, if they're only providing care half of the time, and that can be documented, then he/she is counted as a .5 (FTE).

Now, in some cases, a physician in an area may not be accessible to the population of the area under consideration. And these would be physicians who are considered to have a restricted practice, and you can make and request special consideration in those cases. That determination would be made on a case by case basis by the Office of Shortage Designation that you're working for as to whether or not they would be willing to make an exception or a reduction in the (FTE) equivalent for those physicians.

Now as I mentioned earlier, population groups within your rational service area could also be determined to have a shortage. This would be situation where you have defined your rational service area and you have physicians there based on the total population that would suggest that you have an adequate physician to population ratio.

Let's say at in our situation, you had a population of 10,000, of which- and there were three primary care physicians, leaving you with approximately 1 primary care for each 3300 people, which would be below the threshold of 3500. But within that population, perhaps you have a large Medicaid population. In this case maybe 30% of your residents within that service area are Medicaid. You have a large migrant population. You have a large low-income population. And those three physicians may not provide primary care to those populations or only one of them will see Medicaid patients. And even then, puts a limit on the amount that the Medicaid volume that that physician will see. You can seek to have a designation for the particular population within that rational service area.

And there, you must show that there are barriers that prevent the population group from using the area's primary care providers. Such barriers could be economic, linguistic, cultural, or could involve refusal of some providers to accept certain types of patients or to accept Medicaid. So you could go in and seek a population designation of the Medicaid population within your service area, that they have a particularly difficult time accessing.

The low-income population within your rational service area, the non-English speaking population within your service area. These are all groups that could- you could identify them. You can demonstrate that they have a particular problem accessing the health care delivery system. You can get a designation for them.

So to review, under the HPSA, you can have a geographic, which looks at the entire population based on the criteria that I've outlined, or you can have a population designation, which again is based on a particular identified population within a geographic area.

The next designated process is what is referred to as a medically under-served area designation. Now here, we have to be a little bit more specific than we are within the HPSAs. As I mentioned, in the HPSAs you can have population or you can have geographic. Well, the same thing is true with the medically under-served designations. We have what is referred to as a medically under-served area (MUA) designation but we have a separate, which is referred to as a medically under-served population (MUP). So one is referred to as the MUA and the other is the MUP. MUPs are not available for the RHC program, only the MUA. And that has to do with the wording of the legislation when the program was adopted back in 1977. I can't explain to you why that would be the case, why it was drafted the way it was. But for the purposes of the RHC program, your clinic must be located in a medically under-served area.

Now, the medically under-served area process is different than the health professional shortage area. We spent a lot of time- the health professional shortage area process relies predominantly on the primary care physician to population ratios. The medically under-served area designations rely on health status and other proxy factors, which are indicative of populations who have difficulty accessing the healthcare delivery system. It doesn't rely necessarily on physician to population ratio, although that certainly is part of the formula.

And the MUA process is a scoring process. It involves the application of what is referred to as 'the index of medical under-served areas to data on a service area to obtain a score for the area.' The score is typically anywhere from 0 to 100, where 0 represents complete under service and 100 represents the best possible service available. Under the formula, in order for a community to qualify as a medically under-served area, they would have to have an IMU score of under 62 in order to qualify as a medically under-served area.

Now, the IMU involves four variables. There are four things that we look at to determine a community's score or the rational service area's score: the ratio of primary medical care professionals per 1000 population; the infant mortality rate that exists within that service area; the percentage of population with incomes below the poverty level; and the percentage of the population age 65 or over.

Now, the definition of the service area can be, and it's very similar to the HIPSA, it may be a whole county, groups of contiguous counties, census county divisions in non-metropolitan areas with population centers within 30 minutes travel time. Very similar to what we saw for the health professional shortage area: the latest available data within that service area, what they're going to look for is the resident/civilian/non-institutional population- again, institution essentially being a prison or a facility for the incarceration of individuals- aggregated from individual county and then the- the criteria Census-tracked county population data, the percent of the service area's population with incomes below the poverty level, the percent of the service area's population age 65 and over, the infant mortality rate for the service area or the county or sub county area which includes it.

Looking at the latest five year average is what they're actually going to look at to ensure significant- in other words, that there wasn't perhaps and anomalous occurrence in any particular year. But this is rather something that has occurred consistently, the current number of primary care physicians providing patient care in the area, patient care includes seeing patients in the office, on hospital rounds, other studies and activities such as laboratory tests, x-rays and consulting. And then to develop a comprehensive list, an applicant should check state or local physician (licensure) lists, state and local medical society directories, local hospital admitting Medicaid and Medicare provider lists and the Yellow Pages.

So those are all pieces of information that are going to be brought together to try and determine whether a community or service area has an IMU score that would allow it to qualify as a medically under-served area. Now there are charts which assign a point value to- to the information that the applicant is going to garner. For example, a service area with an infant mortality rate between 12.1 and 13.0 equates to an IMU score of 22.4. A service area with a percentage of population over the age of 65 between 10.1 and 11 gets an IMU score of 19.6. And to determine the overall score, you add the individual score for each category and you get the total IMU. Now in the book that I mentioned earlier, the Rural Health Clinic's How-To Manual, there are charts which show you the actual IMU score that correlates to the statistical or numerical information that the applicant will be asked to provide.

So I made up a community and it's called We're Under-served, Wyoming. And I looked at it and we said, alright, in this particular service area, the percentage of population that was below the poverty level was 25, which related to- has correlated to an IMU score of 10.9. The percentage of population who was over the age of 65 was 20.5, which gave them an IMU score of 9.8. The infant mortality rate, which is quite high of 15; I gave them a 20.5 score. And they had a primary care physician population ratio of .5, which gave them an IMU score for that category of 14.8. You total that all up and they have an IMU score of 56. Because this particular community is below the 62 threshold, it would qualify as a medically under-served area.

Now, the final opportunity or mechanism for designation is what is referred to as a governor's designation. This is an option that is available to each of the state's governors to have an area designated- or areas designated as under-served for purposes of establishing Rural Health Clinics. The states must come up with their own criteria. They submit those to the federal government and generally, the federal government will recognize whatever the states come up with, as long as they determine that it is reasonable and objective and universally applied throughout the state.

What I have done is I have provided you with some examples, and I apologize that the quality is not that great. These were provided to me in a format that made it difficult to translate to a PowerPoint presentation. But these are typical of what the states submit. These do not have to be long; they don't have to be drawn out or convoluted. The first one that I've got here is Nebraska. Nebraska asked that a service area be a single county, partial county, contiguous counties within a defined area, in computing the physician population ratio. They used very similar- in fact, I think it's identical to what the federal criteria for definition. But where they made a change in what they asked for is that their service areas would be designated if there is no physician coverage or if the population to physician ratio exceeds 2000 to 1. So if you remember, the physician- the HPSA designation said 3500 or 3000 to 1. In this case, Nebraska asked that it be lowered for their state to 2000 to 1.

And then service areas where the population between 1500, 1900 to 1 would be designated if at least one of the following need indicators, and then they had various additional criteria so that they could go down to even smaller, lower physician to population ratios if those various factors were prevalent. That particular proposal was approved and in Nebraska, those communities can be designated- that meet those state criteria- can be designated as under-served.

Iowa did something similar. They asked to have their population to physician ratio of 2500 to 1, with a separate measure of 2000 to 1 where the poverty level was above the state average or the elderly population was above the state average. So very similar to what we saw with regard to Nebraska, where they asked to have a lower threshold. And an even lower threshold when they could demonstrate that there were various other characteristics that were prevalent in the community that would perhaps warrant a lower number.

There are about three or four other states, I think, that have asked for and obtained governor's designations. So if this is something that you think might be of interest to your community, then I would encourage you to contact your state and explore the opportunity to have your area done for your state in addition to or in lieu of the federal designations.

At this point, I'd like to open it up for any questions that you may have about anything that I have covered. Operator, if you would tell everybody the instructions for being able to pose a question.

Operator:

Thank you. To ask a question today, please press star one on your telephone keypad at this time. If you're using a speaker phone, please make sure your mute function is turned off to allow your signal to reach our equipment. We'll take as many questions as time permits and proceed in the order you signal in.

(Bill Finerfrock):

And I would ask that when you do pose a questions, let us know who you are and where you're calling from, predominantly the city and state but at least the state. It would certainly be helpful.

Operator:

Once again, that is star one for questions or comments. We do have a question.

(Bill Finerfrock):

Go ahead.

(Beth Ann):

(Bill), this is (Beth Ann) from Michigan. I'm with Health Services Associates. The question I have for you, in the designation process, when I have contacted several state agencies across the country, they are limiting the rational service area to a county only. And that has some real implications for rural pockets throughout the country. What are we doing with that?

(Bill Finerfrock):

That's the first I've heard of it. That is not what's supposed to happen. The service areas can cut across county lines. You know, those county lines are very often political designations that have been made that may have no relevance to transportation, economics, going on in that particular community. So if you have some specifics, we'd be happy to take a look at it. But clearly, the rules and regulations provide for the allowance of service areas that cut across county lines.

(Beth Ann):

Well, I know in Missouri, for instance, I have asked for a- a cluster township rational service area that would include three or four townships and have been told that they only do county designations, that they don't break it down beyond that.

(Bill Finerfrock):

Well, it's not their call. And the other thing that people need to keep in mind is that there is a mechanism or an opportunity to go directly to the feds to seek designation. You can appeal to the federal government. Now, they are going to ask the state for their opinion and they're going to get information. But it is permissible to go directly to the Federal Office of Shortage Designation and go through the process and not have to go through the state.

(Beth Ann):

I've also had a situation in Kentucky where I opted to do that and had been told by the state of Kentucky that I can go ahead and do that but they're not going to provide their review for it once it comes to them from the feds until November. So they're still not going to get to that area until it meets their time frame.

(Bill Finerfrock):

Yes, I'm not saying that it's necessarily a panacea and the states can slow down the process. By the same token, you don't have to be held up by the state. If your state- if the state wants to try and drag its feet - we can try and exercise some pressure. But, you know, it sounds like you're doing what you need to do. Next question?

Operator: Once again as a reminder, star one for questions or comments. We'll take the next question.

(Claire):

Hi. This is (Claire) from the Oregon office of Rural Health.

(Bill Finerfrock):

Hi (Claire).

(Claire):

I was curious about your calculation of physician (FTE) at 40 hours a week. Is that straight patient face to face time or is that including administrative time?

(Bill Finerfrock):

No. Administrative time is not calculated. Now the difficulty is how do you demonstrate what was administrative versus patient time? But it's supposed to be time seeing patients.

(Claire):

OK. Thank you.

Operator:

We'll take the next question.

(Deb Jenkies):

This is (Deb Jenkies) from the Minnesota Department of Health. The question I had is if you could give an example of the definition of current regarding the shortage designations? The previous definition I've had was that three years or newer would include anything that was designated-for instance, in 2006 as well as the three previous years, so 2006, 2005, 2004- am I going right? 2003. So it would be the previous three full calendar years. Is that accurate?

(Bill Finerfrock):

Yes. And that's a- that's a good point, that it is not done by the specific date. I mean, you can go- if you go onto the shortage area list, by the HPSA or MUA list available, it will actually give you a specific date. It may say, May 10th of 2003 was when it was last reviewed and so we're sitting here May 10th of 2006, it would be anytime in 2003. So as long as it had occurred during 2003, it doesn't become ineligible on May 11 because it's outside that three year window. It looks at the entire year and if anytime during that three previous years, that would be acceptable.

Operator:

Anything further, (Claire)? OK, moving on.

(Burt):

Hi. This is (Burt) from (Lunaway) county. I'm just curious about how long does it take once you've requested the health professional shortage area for them to review it and let you know how the designation went?

(Bill Finerfrock):

What state are you in?

(Burt):

Michigan.

(Bill Finerfrock):

Michigan. It's really going to vary from state to state. It depends on your individual state. You know, as you heard from our first caller, some states may want to drag their feet. They are already under requirement to review all health professional shortage areas every three years, and that has slipped a little bit. So, you know, there may be- it may depend upon how many existing HPSAs they have to review that particular year. It may be a factor of how many requests that they get at a particular time for review. I would think that it should be something that could be done within a four or five month time period. But it really is going to vary from state to state as to how quickly they're going to be able to get you through. There is no specific time deadline that they have to complete the process.

(Burt):

Thanks.

Operator:

We'll take the next question.

(Carol):

Hi. This is (Carol) from (Ambiloff) Clinic in (Moston), Wisconsin. I just wanted to clarify, (Bill), the (FTE) for physician counting administration versus face to face. Is it my understanding that face to face would also include not only the face to face with the patient but dictation and telephone follow-up , or administration time would be considered meetings or other type of meetings? Is that correct?

(Bill Finerfrock):

I believe so. The conversations I've had, I believe that that's the case. Administrative would be purely administrative tasks not associated with patient care.

(Carol):

Right. And again, I just wanted to clarify that dictation and telephone call follow-ups would be qualified as face to face?

(Bill Finerfrock):

Yes because you're dealing with a patient, you're delivering patient care. And then the charts, the doing the charts, is all part of that patient encounter.

(Carol):

Yes, great. Thank you.

Operator:

Anything further?

(Carol):

No.

Operator:

Alright then, once again, star one for questions or comments. And it appears there are no further questions at this time. Please go ahead, Mr. (Finerfrock).

(Bill Finerfrock):

OK. Well, I want to thank everybody for participating in today's call and I want to thank the Office of Rural Health Policy for supporting this call series. A transcript of the call will be available, hopefully in a few weeks and posted on the ORHP website for your download. There will be a second call dealing with the operational issues for the RHCs and that will be on Wednesday, May 24th at 3:00 Eastern Time. That will be, as I said, operational and overview of policies and procedures manual and what constitutes an RHC visit and an introduction to the RHC cost report. I would encourage you, if you know others who would be value or value this series, to encourage them to participate. And we will get information out specifically on that call.

In the future, we do suggest that you try and begin dialing in about five minutes before the start time of the call. If you have any feedback, suggested topics, anything that you'd like us to cover or just feedback on the kinds of things that we've presented, the way it's presented, that type of thing, please feel free to e-mail me at info@nhrc.org. The e-mail is part of the slide so you can take it from there.

If there's nothing else, again, I want to thank you for participating and thank the Office of Rural Health Policy for their support.

Operator:

That concludes today's conference. Thank you everyone for joining us and have a great afternoon.

END

  


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