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