Ilene J. Klein, M.D.1Proposal for Rural Health Network

Ilene J. Klein, M.D.1Proposal for Rural Health Network

Development Planning Consultant

September 16, 2005

Ilene J. Klein, M.D.

Project Facilitator

c/o Martha’s Vineyard Community Hospital

P.O. Box1477

Oak Bluffs, MA 02557

Dear Dr. Klein:

I am writing in response to your Request For Proposals for a Rural Health Network Development Planning Consultant.

As you know, I have a two-year history of discussing multi-agency network development with providers on Martha’s Vineyard. I consider this project to be the culmination of that experience and work, and I congratulate you and your partners for your willingness and efforts to reach this point. Since the beginning of my involvement with these early discussions, I have always believed that a network that includes the primary care providers, the Wampanoag Tribe and a critical access hospital is timely, filled with economic and service opportunities, and attractive to grant funders. The inclusion of other providers, as well as other services such as behavioral and oral health, only increase that attractiveness.

To accomplish this project, we have described the history and experience of Stroudwater Associates. When I first started working with Martha’s Vineyard, you knew me as a consultant with BDMP/Westport. About a year ago, we changed that affiliation to Stroudwater Associates, merging two of the strongest national consulting firms with a complimentary blend of experience and history.

To staff this project, we are proposing a team of three consultants. I will be the Project Manger. Larry Pixley has a wealth of experience, and has long been my favorite ‘competing’ consultant prior to our joining Stroudwater Associates. Our styles are different, and I believe we will compliment each other as we work with the providers on the island. The financial analysis will be prepared by Bob Ellis, my consulting partner of over fifteen years. I believe this team represents the best set of skills and experience to work with your group and to accomplish the goals of your project.

Thank you for the opportunity to respond to your Request for Proposals.

Sincerely,

Karen Travers

Ilene J. Klein, M.D.1Proposal for Rural Health Network

Development Planning Consultant

PROPOSAL

RURAL HEALTH NETWORK DEVELOPMENT PLANNING

Consultant Qualifications

Knowledge of rural health care, including various integrated models for delivering primary care services that include physical, behavioral, and dental health care services.

The consultant’s for this project all have in excess of 25 years of experience in health service planning, development and implementation. The historic models have relied heavily on federal and state programs that provide enhanced reimbursement—specifically the Rural Health Clinic (RHC), Federally Qualified Health Center (FQHC) and Critical Access Hospital (CAH) programs. These programs also target services to the un and underinsured, and special populations disenfranchised from the traditional medical model.

We have worked with the RHC program since 1979, developing dozens of these facilities through the construct of new practices, conversion of existing private and non-profit practices, and integration of practices in the provider-based model wherein the RHC is an integral part of a hospital. We have also been recognized as national leaders in the development of FQHC Look-Alikes and federally funded Community Health Centers (CHCs). Likewise, we have worked with the CAH program since its inception.

All of these programs have focused on the integration of services to expand beyond the concept of organizational survival through competition to cooperation and consolidation that will support sustainable systems of care for the community as a whole and focus on the needs of the patient.

The majority of these models have included primary care, specialty medical care, behavioral health and dental services, as well as other services (when appropriate) such as patient education, case management, outreach, public health, acute care, emergency medicine, specialty clinics (such as HIV, methadone, pain management, etc.) and alternative medicine. Models also often have included the rotation of students and the utilization of telemedicine.

Knowledge of key rural health issues, including national and state regulations and legislation.

The consultants are frequent speakers at national, regional and state meetings on key rural health issues, particularly as related to the RHC, FQHC and CAH programs. Staff are often consulted by national and state policymakers about the implications and development of policy issues. Stroudwater Associates is a co-contractor for the Federal Office of Rural Health Policy for its 2004 project to work in five states to Promote Collaboration between FQHCs and CAHs. This project was so successful that it has been extended to 15 states in 2005. This project deals specifically with working in each selected state to promote an understanding of the myths and realities of the complex regulations surrounding these programs and the identification of complimentary or conflicting state regulations.

We have worked with eight states (including Massachusetts) to prepare the statewide plans for the implementation of the CAH program. We are consulting with the State of Alaska in the development of policies for the new Frontier Extended Stay Clinic program. We participated in the development of policies for the new (in 1989) FQHC program. We are often retained to challenge or clarify confusing, and sometimes conflicting, federal policy. We are well versed in new initiatives, such as those focusing on Faith Based Initiatives, the Patient Navigator legislation (HR 1812) recently signed by the President, the Presidential Initiative to expand the number of CHCs by 1,200, and the recommitment to that expansion in the State of the Union address directing the development of a CHC in ‘every poor county’. We stay current on issues such as the current policy effort to arrive at an appropriate definition of what constitutes a “poor” county, the July 2005 General Accounting Office report expressing a lack of confidence in Health Resources Services Administration’s oversight of the CHC program and its efforts to direct the Presidential Initiative to targeted communities with the greatest need, as well as the August 2005 Office of Inspector General report citing that over one-third of currently certified RHCs are not in compliance with federal location requirements, and the call to revise the shortage area designation criteria. We often provide policy analyses for issues such as the recent discussion of continued eligibility for CAH status for hospitals undergoing new construction. We have written definitive policy documents, such as the Comparison of the Rural Health Clinic and Federally Qualified Health Center Program for the Office of Rural Health Policy, which has been recognized as one of its most frequently requested documents, and which has been used by Centers for Medicare and Medicaid Services staff as a resource for regulations in these programs.

In depth knowledge and experience with the financial and operating issues of federal health care designations and programs, including, but not limited to: critical access hospitals, rural health clinics, health professional shortage designations, and exceptionally medically underserved populations.

and…

Proven ability in determining the comparative feasibility of various integrated primary care models, including financial analysis of enhanced reimbursement models for ensuring sustainability of health care services in rural communities.

Complimenting the policy history stated previously in the RHC, FQHC and CAH programs is an equally well versed knowledge of operations and financing of these organizations. We are often sought out as the resource to clarify issues, both at the policy and operational level, such as:

• While RHCs are not prohibited from providing dental services, those services are not (for the most part) cost reimbursable, and in fact may be detrimental to the financial stability of the RHC.
• Why CAHs that support provider-based RHCs may well see a reduction in their CAH cost reimbursement.
• How utilizing the FQHC program can provide savings in the hundreds of thousands of dollars in malpractice insurance that cannot be realized in an RHC.
• Why Medicare and Medicaid coverage limitations affect the delivery of behavioral health care, even though it is a cost reimbursable service.
• How RHCs can receive cost reimbursement for home health services.
• How CAHs can legitimately participate in the governance of a CHC.
• How CHCs can own and operate CAHs, and when this model might be appropriate (or not).
• How CHCs can implement a 340B low-cost pharmacy program, but RHCs cannot.
• How CHCs are provided a Safe Harbor from Federal Anti-kickback penalties, but RHCs are not, and what this Safe Harbor means for CAHs that might be asked to provide financial support for CHCs.

In the development of service delivery models, we prepare financial analyses that probe the intricacies of reimbursement and operational policies such as these, and many others. The financial modeling we prepare usually involves documentation of how much additional funding and reimbursement can be available to an organization or a network, and what regulatory challenges the model must address to access those funds. Our financial models also document why policies that, on the surface, may seem attractive are not necessarily sustainable. For each service delivery model we consult on, we prepare a financial assessment and budget to meet the fiscal goals of the organization.

In the area of shortage area designations, we have prepared dozens of geographic and special population Health Professional Shortage Areas (HPSAs) and Medically Underserved Areas applications. We have prepared these applications for both local communities and organizations, and for states. We recently had the contract to prepare all primary care, dental and mental health HPSAs for the State of New Hampshire, and we are working with several other states that are behind in processing these applications. We have prepared Exceptional Medically Underserved Population applications for Governor submission, as well as statewide policies for the additional Governor designation process unique to the RHC program. We have provided analyses of proposed shortage area criteria, and we are prepared to utilize computer programming to quickly implement new regulations once they are published.

Experience in ensuring culturally competent care.

While the majority of Stroudwater Associates work has been with rural areas, service delivery models for urban-based models is also a priority when those models address the needs of special populations. We have worked with numerous urban models to provide services targeted to the un and underinsured, the racially, economically and culturally disenfranchised populations, and other special needs groups such as the homeless and the HIV infected. In one instance, we actually agreed to support the design of a new health center facility with a segregated waiting room—specifically to meet the cultural needs of a Hasidic population with adamant sensitivity to gender segregation.

We recognize the common myth that cultural issues are less prominent in rural areas. As early as 1979 we worked with a Tribal health center to obtain RHC status and to integrate its cultural and native healing protocols into the traditional RHC model. Since then, we have worked with health care organizations in the Navajo Nation, with Native Alaskans and Native Hawaiians, and with immigrant populations. We have worked with the integration of Latino populations in the Florida glades, new Somalia populations in Maine, Mennonites in Pennsylvania, the very reclusive residents of the West Virginia hollars, and many others. We often work with facilities that have a large patient population for whom English is a second language, or they don’t speak English at all. We focus on operational details that strive to welcome the non-traditional patient.

We have also worked with rural communities where the primary cultural conflict has been an historical football rivalry. We have found this conflict to be one of the most difficult to overcome.

We also recognize, and have experience with, the special cultural issues facing island-based health care organizations, and have worked with these groups in Massachusetts, Maine, Washington, Alaska and Hawaii. Through this work, we have gained an understanding of the issues of isolation, claustrophobia, lack of privacy, economic cost of living, difficulties in recruitment and retention, and differences in year round and off-island residents.

Ability to work with traditional and non-traditional healing modalities.

Some of the examples above support our history with the integration of cultural non-traditional healing modalities. However, we also have worked with numerous organizations to successfully integrate other non-traditional modalities such as chiropractic, touch and massage therapies, and herbal medicine. One favorite example is the CHC that developed a pain management clinic with a clinical team consisting of a physician, a dentist, a psychologist and a massage therapist.

We recognize national reports that document the reality that 80% of Americans are purchasing health care outside of the traditional model—often at their own expense. We believe that any successful health care model is foolish to not recognize and address this population driven demand for alternative health care modalities. Our goal is to develop models where these modalities are integrated with the traditional medical model in a complimentary and coordinated way.

In-depth strategic planning experience with demonstrated expertise in community consensus building on group based strategic plans.

All of this history in service delivery model development has involved intense strategic planning. The majority of projects, particularly for the CAH and CHC (FQHC) programs have involved consensus building within a community of health care professionals and the community at large. We often conduct key informant interviews and/or focus groups. Examples of specific projects include:

• The integration of two private physicians and a public health department with a CAH in West Virginia
• The integration of private physicians in numerous communities with CHCs
• The divesting of a hospital provider-based RHC and merger of that organization with an existing CHC in New Hampshire
• The divesting of a community indigent care clinic from its two corporate members—a Catholic and a Baptist hospital, with conversion to a freestanding non profit organization

In our experience, community based consensus building that leads to collaboration focuses on strategies, such as:

• Helping people understand which issues are within their control, and which aren’t
• Identifying, and focusing on, What Problem Are You Trying To Solve
• Helping people understand that if you don’t use a service, you will lose it
• Identifying the elements of control, and dealing with those, rather than allowing the discussion to center on a term as ill defined as just ‘control’
• Recognizing that each organization should be willing to go out of business, if that is in the best interest of sustaining viable services in the community, and that doing so does not necessarily mean the loss of jobs
• Acknowledging leadership egos, and mitigating the sometimes detrimental aspects of those egos by including larger (staff, board, etc.) participation from the organization
• Acknowledging leadership egos and skills, and fostering the positive aspects of those
• Backing up anecdotal stories with documented facts
• Fessing up to football rivalries (or the equivalent)

One favorite example of communitywide consensus building is with the Webster County Memorial Hospital in Webster Springs, West Virginia. In this example, the community hospital was failing, with an average daily census of less than one patient. The two local primary care physicians were boycotting the hospital, and not speaking to each other. They were very adamant about retaining ‘control’ of their practices. The Public Health Department was basically providing a broad range of primary care services in a manner considered substandard by the hospital and the physicians. The community felt that ‘if we could just recruit another general surgeon’ we could fill up the 100 empty beds in the hospital.

We worked with the community to bring all of these factions together. The physicians identified the elements of their practices that they needed to retain control over, and became employees of the hospital. The Public Health Department was relocated from a terrible warehouse to unused space in the hospital. The hospital did not recruit a general surgeon, but did recruit additional primary care physicians and mid-level providers. The community pharmacy relocated into the hospital, as did the local social services agency. The hospital converted to CAH status. This all happened in 1991 and 1992. The relevance of this example as one of our successes is the fact that we have recently been retained to conduct the fourth, five-year strategic plan for this community, including the construction of a new hospital facility.