Attending: David Haden/for Linda Atkins, Chuck Conner, Norm Ferrari, Tom Hefner, Jill Hutchinson, Shirley Neel, Jim Nemitz, Jessica Sharp, Bob Whitler.  Staff: Alicia Tyler.  Absent: Robert Blake, Mike Holt, Mike Lewis, Jill McDaniel, Jo Ann Raines, Lynne Welch, and. Guests: Jill McClung, Caryl Kramer,  Jeff Werner, Melissa Wheeler, Bob Walker, Jennifer Plymale, John Russell, Steve Thomas.

Bob Whitler, substituting for committee chairman, Dr. Mike Lewis, opened the meeting. The minutes of the May 15th meeting were approved.

Rural Residency Training

Alicia reported passage of H.B. 205 during the special legislative session to allow transfer of $1.4 million in higher education funds to a special Medicaid account to qualify for 3:1 federal matching funds.  The funds would be used to support existing family practice residencies and to expand  rural residency training.  A committee is working to develop a State Plan Amendment, which requires federal HCFA approval.  Bob Walker, who is on the committee, said this is a important step for the state, which could change the focus of graduate medical education from high tech teaching hospitals to rural sites.  The committee had several questions/comments for Dr. Walker:

 • Need to consider if this would increase demand on FP student preceptors.
• Rural residency programs need waivers of national FP accreditation standards. May be possible to get a broad, statewide waiver.  Jill Hutchinson reported on a federal initiative to develop performance accreditation standards for community health centers.  WV has already developed performance standards for primary care centers that, if met, could help these sites get waivers of federal standards.  They may also help obtain a waiver of FP accreditation standards.
• Would this involve new or existing residents?  Probably both.  Rural programs need to be linked to existing programs.
• Would residency caps (on training slots) apply?  Not sure at this point.
• Are there things that rural centers can do to prepare?  No. WVRHEP already has an excellent training infrastructure with computer linkages.
• How would residents and sites be selected?  Several things could drive this – truly underserved areas, sites that want to sponsor, and desires of residents.  Need a range of opportunities so we can recruit nationwide.  Current rural residencies with existing waivers will be supported.

Mental Health Recruitment Needs

John Russell, executive director of the WV Behavioral Healthcare Providers, gave a report:

• Behavioral health is a $300 million industry in WV with 81 licensed facilities.  The system has always had recruitment & retention problems, which are worse now.  HCFA disallowances of $10 million in state funds have caused a $50 million hole in the Medicaid budget.
• The DHHR Office of Medical Services is issuing new rules in November for Medicaid payments to “assertive community treatment (ACT) teams.”  People will be served in their communities and homes.  It is estimated that 25+ teams, staffed by psychiatrists, psychologists, nurses, and social workers, will be needed in WV.   ACT teams must focus solely on ACT clients.
• Psychiatrists are the greatest need.  Most centers contract with private providers.  Seneca Mental Health Center recently recruited a Bulgarian psychiatrist from New York City. New licensing changes will create greater need for social workers.  Case managers are also needed.
• In WV, WVU/Morgantown and Charleston produce 6 to 8 psychiatry grads a year.  WVSOM has some grads that enter psychiatry residencies out of state, but this field is not a major focus.
• Jim Nemitz asked (1) Where do psychiatrists find out about job opportunities?  (2) Is the need  increasing?  Mr. Russell said that out-of-state locum tenens firms contact his office.  The Division of Recruitment (DOR) also lists psychiatry needs.  Jim knows of a WVSOM grad in psychiatry in Iowa who wants to return to WV. He suggested that the Association, DOR, and the medical schools collaborate to recruit psychiatry graduates back to WV.
• Shirley Neel asked if ACT teams would work through existing facilities – or must they be part of the existing 14 behavioral health centers.  Mr. Russell said this is in dispute.  State is reconsidering original requirements and is profiling areas for eligibles.  In the end, will probably allow “any willing provider.”
• The behavioral health center model is more suited to metropolitan than rural areas.  Need new models that are more integrated with primary care.
• Jill reported that Valley Health Systems and Shenandoah are discussing linkages with local behavioral centers.
 
J-1 Placement Policies

Alicia reported her conversation with Mary Huntley, Office of Community & Rural Health Services, about state J-1 policies, which do not allow placement of specialists.  DHHR has received four requests for placement of specialists and subspecialists and wants the committee to consider a policy of allowing more flexibility.  Alicia provided an overview of J-1 placements in West Virginia, including problems of program abuse before current policies were adopted. She reviewed other state J-1 policies re. definitions of primary care, placement of specialists, policies toward specialty training, and definitions of underserved areas. Many states will not consider specialists, but some states will on a case-by-case basis or under special circumstances.

Jill Hutchinson supported the concept of allowing placement of some specialists.  The primary concern should be meeting community needs.  Other points made in discussion were:

 • Need flexibility for two or more sites to share a specialist. WV had problems in the past with NHSC placements, because the feds would not allow sharing arrangements;
• There should be a limited amount of specialty placements, but require the community to document that they’ve tried to recruit American physicians. (Div. of Recruitment does require sites to submit proof of such efforts during the 6 months preceding their J-1 application.)
• A distinction should be made between J-1 applications from a small rural hospital wanting to recruit for the community and an urban group practice wanting to place J-1s in rural sites for patient referrals. The latter caused program abuse in the past.
• WV does not have a coordinated effort to recruit American-trained specialists.  Hospitals usuallly do this. (We are developing coordinated placement of primary care physicians.)
• A primary reason for J-1 recruitment has been economic.  They work for less, and sites have budget constraints.  J-1s have filled a gap in rural health care.
• Needs arise in communities, and we need flexibility to respond.  BUT, there are negatives: (1) We shouldn’t have to recruit by default.  Our goal is to have doctors come to rural WV who want to be there.  (2) Subspecialists aren’t trained to work with primary care physicians.  We need contract provisions to require collaboration with primary care physicians.
• The health care system needs to be focused on chronic disease management.  Bob Walker said that in McDowell Co., diabetes is a major problem.  In this case, an endocrinologist could work well with primary care physicians.  In WV, good areas for collaboration would be management of diseases of the heart and lungs, as well as diabetes.  We need to be careful how we do it.  It shouldn’t be based just on economic development.  On the other hand, Bob Whitler said that the loss of specialists and subspecialists in a rural county such as Logan means the loss of millions of dollars in hospital revenue.
• One health center hired a J-1 physician and laid off several mid-level staff.  We’re faced with cruel choices in rural health because of budget constraints.  This is a case of doctor by default.
• Jill Hutchinson said that communities are best equipped to identify need.  She suggested the state  (1) consider on a case-by-case basis, based on documented need; (2) build in contractual requirements; and (3) allow sharing of providers.
•  We should consider requests from MUAs – for example, McDowell Co. has very high need, but does not meet HPSA criteria.

On motion (Nemitz/Hefner), the committee voted to endorse in general the concept of more flexibility in recruitment of J-1 specialists and subspecialists , reviewed on a case-by-case basis, based on the following principles:

•  documented community need;
•  allowing for sharing and networking of specialists;
•  enhanced policies, procedures, and contract requirements; and
•  allowing placements in MUAs as well as HPSAs.

Bob Whitler asked for volunteers to serve on a subcommittee to review and make recommendations on the J-1 policies for the November 20th meeting.  Members include: Jill Hutchinson, Jennifer Plymale, Chuck Conner, Alicia Tyler, Bob Whitler, Melissa Wheeler, and David Haden.

The meeting was adjourned.