Wyoming Healthcare Commission Meeting Minutes
June 28, 2004
Riverton, Wyoming
Attendance
Commissioners Dr. Jack Glode, M.D., Carol Jenkins, Steve Mossbrook, Chris Muirhead, Dixie Roberts, and John Vandel; Ex-Officio Commissioners Deborah Fleming, Ph.D., and Ken Vines; and Director, Diane Harrop, and Executive Assistant Emily Genoff.
Meeting called to order, 8:09 a.m.
Chairman Muirhead announced that the Governor will soon name a new Commission member to replace Commissioner and attorney Ford Bussart of Rock Springs, who resigned this month. Chairman Muirhead introduced the Commissioners and staff.
Presentations
Wyoming Department of Health Office of Rural Health Manager Lynne Weidel and Wyoming Primary Care Association Executive Director Sharon Montagnino were introduced to present current and future opportunities for healthcare delivery in the state (handouts, Rural Health.ppt, Rural Health2.ppt, Rural Health3.ppt). Models funded by government include a number of “Section 330” primary and preventive healthcare programs: community health centers (one in Casper, satellite in Dubois), healthcare for the homeless clinics (Casper, Cheyenne), migrant health centers (BigHornBasin), and mobile healthcare delivery units and public housing primary healthcare and school-based health centers (none in operation in Wyoming). The government also supports rural health clinics, and critical access hospitals (CAHs) through improved reimbursement. Free clinics (in operation in Cheyenne, Laramie and Jackson) are not government funded or regulated, typically.
These programs were launched and operate to address the preventive and primary care needs of populations that cannot or are not accessing healthcare due to absence of healthcare coverage (private insurance or publicly funded SCHIP, Medicare or Medicaid programs), income, location or other barriers. Section 330 programs typically employ health professionals who have federal medical malpractice protection. Services may include dental and mental health, prescription drugs, and social work and case management services. Free clinics are staffed by volunteers. Rural health clinics and CAHs resemble competitors in the private sector.
There are 21 rural health clinics in 10 Wyoming counties. They employ mid-level (physician assistants, nurse practitioners) health professionals. Some rural health clinics in Wyoming considered becoming Community Health Centers to tap into federal grant programs. For a rural health clinic to convert to 330 program status it must become a nonprofit agency and work for a governing board made up of consumers and other community residents. Rural health clinics receive higher reimbursements from Medicare and Medicaid than private physician providers. Section 330 programs and rural health clinics must be located in health professional shortage areas. Free clinics are not regulated by the federal government and may be set up in any location. CAHs receive additional funding through cost-based reimbursement.
What does the future look like for community-based healthcare? Federal funding is still available for creation of new 330 program sites. The WPCA is working with communities intent on creating better healthcare access for homeless and low-income populations. The WPCA is providing technical assistance with Section 330 pre-application research and the application process, which is lengthy and potentially overwhelming.
Challenges for community-based healthcare include Wyoming’s frontier environment, distinguished by population density, and distance between communities with healthcare. Three percent of America is classified as frontier and encompasses 50 percent of the country’s landmass. Wyoming is the “top ranking” frontier state, with 74 percent of the state’s population and 93 percent of the landmass falling within that category (21 of 23 counties). Frontier communities are isolated, lack specialty care and long-term care facilities, have limited consultation and continuing education opportunities for healthcare professionals and there is a shortage of state-of-the-art technology in Wyoming.
To tap into federal healthcare clinic program dollars (including the National Health Service Corps health professional education loan repayment program), communities and counties must be designated as mental, dental and primary care health professional shortage areas and/or a medically underserved area/population. The criteria for shortage areas are more applicable to rural and urban areas than to frontier communities. A designated community might be a portion of a town where low-income people and/or minority groups reside. Nonetheless, Wyoming’s low population numbers, ironically, prevent many populations and communities from meeting the level of need as determined by the federal government to qualify as underserved. Even if a community is designated and puts a federally funded clinic into action, continued funding isn’t assured; funding ebbs and flows with federal political shifts.
Work is being done to improve the data available for designation of communities or populations without healthcare access; a study of Wyoming’s homeless population is anticipated and a data conference has been scheduled. Changes in health professionals in a community must be closely monitored to ensure opportunities for designation are not missed. The SORH, WPCA and Wyoming Health Resources Network are partnering to increase the opportunities for communities to access federal programs.
Wyoming Department of Health Director and Ex-Officio Commissioner Dr. Fleming said an increasing shortage of housing for low-income families in Wyoming is anticipated. She said there’s a need to create a public housing authority office within state government, or whatever is needed to obtain funding for a healthcare program based in public housing.
Catherine Keene, Director of Indian Health Service’s Wind River Unit, discussed the provision of medical care to Native Americans in FremontCounty(handouts, Keene1.pdf, Keene2.ppt). From 1800 to 1849, Army physicians were in FremontCounty under the War Department. The hospital on the reservation provided services to the community. In 1955, Indian Health Services was created to improve the health of Native American populations. There are 12 regions within Indian Health Service. The Wind River Unit is within the Billings, Montana, region. Services are provided directly or through contracts with healthcare providers in Wyoming communities. Nutrition and diabetes education and management, alcohol and substance abuse treatment, dental and mental healthcare, and sanitation (water and sewer) are among the services provided by IHS.
Any enrolled member of any tribe can receive services at IHS facilities. The Wind River Service Unit has 15,000 people registered, with a healthcare user population of 10,000. Provider visits totaled more than 40,000 in 2003, with 46,000 visits projected for this year at the two available facilities. IHS providers are covered by federal tort but have to perform their duties within their scope of work and can only see Indian patients. Eligibility requirements for contract health services outside the clinic are strict because funding is limited. IHS operates on a managed care system of referral because dollars are fewer than healthcare needed. Prior authorization for care is required. Contract health expenditures average $6.3 million – the budget for those costs, however, was $5.5 million. Additional funding is sought from resources offered competitively nationwide. Deferred services are increasing, impacting vendors and patients (this fiscal year, more than 500 deferred cases are anticipated). More than $4 million worth of services billed by healthcare providers were denied payment. Orthopedic services and transplants, for example, are not funded. In 2004, projected denied payments will total $5 million. Diagnostic procedures are becoming more limited.
About 30 percent of the Wind River Unit IHS user population has no other form of healthcare coverage (Medicaid, Medicare, private insurance). Medicare reform is allowing for increased billing for Native Americans that will provide better funding in some cases starting in 2005. Drug cards also will be available. IHS has Medicaid authority and its population is about 37 percent Medicaid enrolled. About 20 percent of IHS Wind River patients are privately insured or have Kid Care CHIP coverage. Podiatry, nephrology, orthopedic, prenatal, psychiatry, ENT, audiology and surgery are contracted, clinic-only services. IHS has seven physicians – one is a pediatrician, and there also are psychologists, dentists, optometrists, pharmacists, three family nurse practitioners and a physician assistant available. Some are commission corps officers. Ambulatory healthcare facilities are in Ft. Washakie and Arapaho. There are between 50 and 100 walk-ins a day at the clinics, which are open 8 a.m. to 8 p.m. Monday through Friday, 8 a.m. to 5 p.m. on Saturday and 10 a.m. to 6 p.m. on Sunday, reducing ER visits. Prevention efforts are underway and are positive – immunization rates, for example, are over 90 percent for infants and adults. Native Americans still experience greater death, disease and disability rates in Wyoming than other minorities and the general population. Specialty care is limited. Payment priority is given to trauma and other life-and-death and potentially high-dollar cases.
Average age of death in 2002 was 52. End stage renal disease, cancer, diabetes, smoking and motor vehicle accidents were leading causes of death. At least 40 percent of the population smokes. Alcohol and substance abuse related deaths are significant. The Wind River Unit is the lowest funded in the Billings area. New facilities would increase funding from 51 percent to 60 percent. The likelihood of getting a new facility, however, is slim because existing clinics are carefully maintained and renovated. Provider leadership shortages are anticipated. IHS headquarters is undergoing reorganization.
An electronic health record system is being implemented. All providers but dental are online. The goal this year is to have 12 sites up and full implementation by 2008. Veterans Administration (VA) IT systems have been adapted for IHS. Discussion followed regarding how physician times have been slowed, and the number of patients diminished, by the implementation of electronic medical records. Partnerships are being developed with the Wyoming Department of Health and the Social Security Administration, in addition to the VA. A better business model is being explored. National data shows that the IHS budget has stayed flat while the Native American population has grown and healthcare costs have increased. A 20 percent population increase in Wyoming is anticipated due to the number of Native Americans who are under the age of 25.
University of Wyoming College of Health Sciences Dean Robert O. Kelley presented what the state is doing for medical education (handout, UW.ppt). Medical education is important to Wyoming because it is tied to economic and community development, generating personal income and retaining health-related dollars in communities. Associate Dean of Medical Education and Public Health Dr. Jim Page has been working to determine what the return on investment is, in dollars. An individual physician in a rural community will generate $2.4 million in income (the physician retains just 5 percent to 10 percent.) The jobs generated by healthcare in rural communities tend to be high-quality jobs. Medical loan repayment-devoted funds are well invested because physicians who are educated and do their internships through that program generate significant dollars for the communities they practice in and the state as a whole. Wyoming’s ability to provide medical education to its citizens is important. If we didn’t provide an option for youth to go to medical school, families would move to other states where those opportunities are available. Wyoming contributes to the Western Interstate Commission for Higher Education (WICHE) and WWAMI (Wyoming, Washington, Alaska, Montana, and Idaho) to create medical education slots for Wyoming students in other states’ medical schools. The residency programs in Cheyenne and Casper train medical school graduates to practice. Nationally, there is a diminishing physician workforce and family practice physician numbers, in particular, are dwindling. The family practice residencies in Wyoming are a significant contributor to the healthcare delivery system in the state, treating a large number of uninsured patients.
WICHE allows students to attend professional schools in 15 states at reduced tuition rates; WICHE dues total $236,000 and student support is $3.78 million (note: WICHE students are not all medical school-enrolled – some are in other professional education programs – some are studying veterinary medicine, or even architecture). To qualify for WICHE, a student must have been a resident of the state for three years prior to matriculating. Since 1953, more than 1,400 Wyoming students have been supported through WICHE. The average tuition rate is about $14,614; the support fee is about $24,000. In 2002, there were 26 Wyoming students supported in WICHE and in 2003, there were 29. WICHE students have no obligation to pay back Wyoming for the cost of their educations OR to return to Wyoming to practice medicine. Other states, such as Nevada, have used WICHE programs as workforce programs; students in those states have to pay back the dollars and/or come home to practice their profession. There is an inflator on medical education – the costs continue to go up annually. Support fees have been raised by other states, up to $25,000 on average. Fewer students can be supported for the same dollars. Dr. Kelley said he wonders if there should be some linkage between WICHE and residency programs. The best and the brightest students are going to WICHE.
WWAMI enrolls 10 new students annually. Those students spend their first year at the University of Wyoming, and the remainder of their years in Washington state. Students pay back the difference between what the state pays to reserve seats for their state at the University of Washington. They can repay the funds in 96 equal payments or via three years of service. Last year, the Legislature decided that if students do their residency in Wyoming, they then only have to pay back one year’s worth of expenses. Wyoming pays about $1.9 million to the University of Washington for this contractual commitment (40 students annually), plus $600,000 is spent annually at the University of Wyoming for first-year medical education. Of eight students in the first WWAMI class, four have completed their residencies and are returning to Wyoming. There are now 25 students in residency (residency takes three to four years). A return rate of 40 percent to 50 percent is anticipated. Some will opt to pay back their loans and not practice here. Dean Kelley is concerned about the quality of the state’s residency programs and said he debates with himself over the policy issues implicit in WICHE and WWAMI and which benefits the state more, whether there should be a resource shift from one program to the other to benefit the state’s health professional workforce.
The residency programs show a high rate of health professional retention. Residents provide the only healthcare in Pine Bluffs, deliver about 25 percent of the babies born in Casper and provide several hundred thousand in charity care in Cheyenne. Meanwhile, there has been a loss of senior leadership. Faculty physicians are difficult to retain. Inadequate staffing leads to underutilization of facilities and capital equipment and facilities are then difficult to maintain. Dean Kelley discussed options for increasing funding for the residency programs, including resizing the programs, asking the Legislature for a new state medical education budget category (outside of the UW block grant) and shifting more costs to students. He detailed the funding structures for the residency programs. In 1991, there was a reallocation in Wyoming and the University was asked to return dollars – including money from the residency programs, which were then required to earn a portion of their base budgets from the practice of clinical medicine. Income from clinical medicine has never gotten the residencies back to base 1991 funding levels. The state is putting about $10 million annually into medical education and getting an excellent return on its investments. Relative to other states, however, it’s not as effective as it could be and questions of quality are arising regarding whether the students attracted are good enough.
Discussion followed regarding the operation of the residency programs and the problems associated with attracting the best and brightest students. The state pays the residents’ salaries, a portion of faculty salaries, and a portion of the cost of operating the Community Health Center in Casper to which the residency program there is tied. Cheyenne’s system is funded entirely by the University of Wyoming.
Other types of recruitment and retention methodologies were discussed. Dean Kelley and Dr. Page said a residency program is more effective than what’s been tried -- or what’s been tried in other states isn’t comparable, given Wyoming’s needs for doctors specifically trained to practice in frontier and rural settings. But Wyoming’s ability to compete for the best medical school graduates (based on the pay provided in residency) is put at a disadvantage because the state is spending less than other states.
Ron Ommen, St. John’s Hospital CEO, discussed a forum his community led on medical malpractice issues. He said he wrote a letter to the Governor and the Commission following the Jackson forum outlining solutions for the medical malpractice crisis based on the findings of the forum. The result of the Jackson meeting was that there was no agreement on captive insurance. That was rejected by the physicians because of the risk involved, Mr. Ommen said. But there was “wobbly” interest in former Gov. Mike Sullivan’s proposal for a medical review panel. The concept of what Gov. Sullivan had discussed was brought up by Rich Jamieson, another Casper attorney. Under that model, if a patient questions an outcome following a medical procedure, that potential litigant would go first to a panel whose findings would be mandatory and binding. Negotiation of payment for patients found to be injured would be dealt with out of court unless an agreement can’t be reached, and then a trial would be held. It’s the type of compromise required to bring needed stability to medical malpractice insurance rates. The strength of the proposal is that it does allow for a speedy conclusion, doesn’t limit access to trial by jury and allows for unlimited recovery (with the state paying the damages in some cases). Mr. Ommen said he likes the plan because it combines speed, certification of expert witnesses, with respects for people’s rights. It can result in system change that benefits payers and providers. There are no guarantees that anything we do will induce new insurers to write medical malpractice insurance in the state.