Wyoming Healthcare CommissionAugust 23, 2004 Meeting Minutes

UW Alumni House – Laramie

Attendance:Chairman T. Chris Muirhead, Commissioners George Bryce, Jack Glode, M.D., Carol Jenkins, Paul Lang, Steve Mossbrook, Dixie Roberts, Jack Speight, John Vandel, Ex-Officio Commissioners Kenneth Vines, State Insurance Commissioner, and Deborah Fleming, Ph.D., Wyoming Department of Health Director, and staff Diane Harrop, Director, Emily Genoff, Assistance Director, and Jan Kruse and Kathy Krubeck, Project Coordinators.

Meeting called to order, 8 a.m.

Chairman Muirhead introduced the Commissioners and staff.

University of Wyoming

The first speakers he welcomed were Dr. Philip Dubois, University of Wyoming President, Dr. Thomas Buchanan, Vice President for Academic Affairs, and Dr. Robert Kelley, College of Health Sciences Dean, to talk about the University’s support for medical education and specifically, legislation passed during the Special Session of the Wyoming Legislature in July (HB 1008/Enrolled Act No. 1 (handout, UW.pdf)) that focuses on medical education programs.

President Dubois said the three primary medical education opportunities at or via the University of Wyoming cost a total of almost $8 million per year and are: the Western Interstate Compact for Higher Education (WICHE) the consortium agreement University of Washington, Wyoming, Alaska, Montana Idaho (WWAMI), and the UW Family Practice Residency Program in Cheyenne and Casper. Even though the budgets of the Colleges of Education and Business together total less than what is spent on the combination of WICHE, WWAMI and the UW Family Practice Residencies, there is no clear state or University philosophy under-girding these programs, he said.

WICHE, operated by 17 western states, was founded in the early1950s and has within it a student tuition reciprocity agreement. Wyoming uses WICHE as a means to provide access to expensive professional education not available in the state, including more affordable degrees in medicine and dentistry. Students selected to enroll in a professional school out of state will pay residency tuition out of state under the WICHE program. The state of Wyoming steps up to subsidize that student’s cost to the out of state institution. On average, a medical student will pay $14,600 in tuition. Wyoming pays a negotiated standard support payment that all the WICHE institutions and schools agree to. That payment is high enough that the schools in other states are willing to take Wyoming students for the standard support payment but that payment doesn’t represent the full cost of students’ education and there is unhappiness in some states that support payments are

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too low, President Dubois said. The highest payments are for medicine and veterinary medicine and total roughly $24,000 per year.

The WICHE Commission, upon which President Dubois sits (with state Sen. Tex Boggs, Western Wyoming College President, and Klaus Hanson, the Modern and Classical Languages Department Head and a professor at UW), sets the number of slots available for students. The Commissioners don’t look at workforce needs when determining which professional education opportunities are funded for students; instead, awards are based on student demand. For example, veterinary medicine applicants are numerous but there is no known shortage of veterinarians in the state. The WICHE Commission largely responds to recommendations that come from Dean Kelley and his office, President Dubois said. There are four to five medical student applications funded per year and four to five WICHE medical school students graduate each year.

Fields outside of medicine (physical therapy, optometry, dentistry, architecture, occupational therapy) consume 90 slots, and of them veterinary medicine is the largest. WICHE participation costs Wyoming a total of about $2 million annually. But there needs to be a closer link between what Wyoming spends on WICHE and what the state needs in the way of professionals, President Dubois said. Students are not expected to pay Wyoming back for the opportunity to participate in WICHE and there is no requirement that they practice their profession in the state. In other states there are payback agreements.

There is no linkage between WICHE, WWAMI and the residency programs. The emphasis on WICHE has been on access to medical education, not on the availability of medical care in Wyoming, President Dubois said. The support fees are rising and are going to continue to rise but if fees don’t rise, out of state institutions will not take other states’ students. WICHE has no ability to respond to healthcare needs when student demand falls. Only two students applied in dentistry this year. Meanwhile, Wyoming faces a shortage in the future as dentists retire and few are available to replace them. And even if there were more students seeking dentistry education through WICHE, there is no guarantee any of them will practice in Wyoming. President Dubois was asked whether there are states with models more applicable to Wyoming’s needs than the model in place now. President Dubois said he did not know but the University would research that question. WICHE has its own state budget administered by UW. There is no way to track where WICHE-funded graduates reside once they have graduated from college (handout, WICHE.pdf).

The clear philosophy behind WWAMI is physician supply, President Dubois said. The program accepts the enrollment of 10 medical students per year and there are a total of 40 students at any one time. Tuition for WWAMI is $7,158 annually. The intention is to encourage students to go into medical education. But there is a tradeoff -- students are required to pay off their educational debt in 96 equal payments or come back to the state and serve three years as medical practitioners. The program costs are in two components: what UW has in its budget for first year medical education and what is paid to the University of Washington for students’ three remaining years. There is a known

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relationship between where students’ residency is done and where their professional practices are set up. It costs Wyoming about $62,000 to educate a WWAMI student. The total Wyoming commitment is $2.5 million per year. However, WWAMI requires periodic cost adjustments. The University of Washington’s tuition increases 3 percent to 5 percent per year but in order for the University of Wyoming to pay more, a case has to be made before the Legislature to justify that additional expense. The University of Wyoming would like to see WWAMI accorded a separate state budget like WICHE gets.

During the Legislature’s Special Session in July, a bill was passed mandating an increase in enrollment in the WWAMI program, “up to an additional six first-year medical students for the fiscal year commencing July 1, 2005, thereby increasing class size from 10 to at least 12 and up to 16 students. The University of Wyoming shall include in its budget request for the 2007-2008 biennium sufficient funding to sustain the size of each class at not less than 12 students and not more than 16 students. The goal is by the fall enrollment of 2007 the first year class shall have a capacity of 16 students.” The Legislature also directs the University to explore expanding to 20 students per year. In addition, the bill asks UW to “explore the potential of expanding or subsidizing to a larger degree than current practice the family practice residency programs in the state,” and to “explore the potential for alternative scholarship programs for medical programs from this state.”

The Legislature wants to assure the participation of 80 students in the program at any one time, President Dubois said. But the cost of doubling the program’s size and its capacity to take on that many more students are problems the state is facing now, he said. More faculty and bigger classrooms will be needed. Third- and fourth-year clerkships have to be set up across the state in existing medical practices. Wyoming has only one year’s worth of graduates from the WWAMI program who have completed their residencies. The question now is whether there is a good fit between where students choose to practice versus where there is demand is for physicians. The statute requires students to return to the state to be entitled to have their financial burden reduced, but state law doesn’t mandate that they go to Newcastle or Wamsutter or another rural community in need of medical professionals. As the state expands the amount of money being spent on medical education, options for attracting and retaining physicians in the state should be weighed, President Dubois said.

The Family Practice Residency Programs in Cheyenne and Casper have three purposes: medical education, physician supply and community health. The University of Wyoming took the lead in developing the Community Health Center in which the Casper residency program is housed, President Dubois said. The University was losing $500,000 a year on the provision of medical care in Cheyenne and in Casper but the creation of the CHC stopped UW’s budgetary hemorrhage in Casper. There are 24 medical residents in Casper and six supervising physicians, and there are 18 residents in Cheyenne with five supervising physicians. The University’s total budget commitment to the two sites is $4.6 million and more, including clinical income. The residency programs are successful; there have been 250 graduates since 1975 of which 40 percent to 50 percent start practicing in Wyoming.

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Clinic income is well under 50 percent of operational costs. For Cheyenne, the clinic income is about 40 percent of the total budget. It is harder to tease out what the cost is in Casper because of the agreement with the CHC for a residency site. The contract with the CHC is being renegotiated. There are new federal rules that are phasing out federal graduate medical education reimbursements, increasing financial pressures on the CHC.

Director Harrop asked whether the University is willing to consider some kind of formal network for plugging family practice residents into recruitment networks in Wyoming. She noted she met a young man from Casper who had just finished the residency program and reported that he had been recruited by Montana and Idaho but not Wyoming. Wyoming Health Resources Network Director Pennie Hunt noted that her organization’s representatives go to the residency programs each year to remind students of the value of coming back to Wyoming and visit with them when they are doing their clerkships. Discussion followed regarding the difficulty of recruiting students to Wyoming who are domestic and likely to want to stay here. Even though medical students are graduating with high debt loads, they are looking for places to settle where there is likely to be high income to cover their loans and malpractice insurance.

Wyoming is low in its total compensation for resident physicians but UW is doing what it can to bring those levels up, President Dubois said. University of Wyoming WWAMI Director Sylvia Moore said five people have completed medical residencies this year and three are in practice in Wyoming -- two are in Casper at the CHC, one is in Jackson. The remaining two are out of state but are working on opportunities to come back to Wyoming. The University’s faculty salaries are below national averages making recruiting physicians to instruct residents more challenging. Wyoming students’ Medical College Admission Test (MCAT) scores are lower than all other WWAMI states’ students. The legislation mandating expansion of the program allows the acceptance of only “qualified” students, but questions remain regarding whether there will be enough qualified applicants to expand to the legislatively mandated level. In the history of Wyoming’s participation in the program, only one student has dropped out.

Rick Miller, UW Vice President for Government, Community and Legal Affairs, said the University has sufficient funding to cover the second year of the bienniem with more WWAMI students. The high cost comes in years two, three, and four and the University will have to put in an exception budget request to cover the additional students in the expanded program. Efforts are being made to encourage more interest in medical careers. There is a “pipeline program” called UDOC that hosts activities throughout the state to get interest in health careers and medicine but a pipeline takes a long time to generate measurable results. There is also a three-week “mini DOC” pilot program in its second year at Central Wyoming College in Riverton designed to target the Native American population there. The underlying theory is that students who are from Wyoming originally are more likely to want to settle here or in similar rural and frontier areas after obtaining their medical degrees. There is no access in Wyoming to MCAT preparation programs but efforts are being made to launch one in the state.

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Representative Jerry Iekel and Senator Charlie Scott said that there have been ongoing physician shortages in the past that were temporarily alleviated by refugees from managed care. But managed care has been beaten back sufficiently in other states to stem the tide and there are once again “normal” shortages of physicians in the state. Policymakers are looking for something to do to expand physician supply in the long term and understand what the cost will be. Discussion followed regarding physician recruiting and the fact that the CHC has been able to recruit successfully because it is partially federally funded, is federally approved and can offer medical malpractice protection under the Federal Tort Claims Act. It is difficult in Wyoming for private practice physicians to compete with a CHC. Dr. Moore noted that the medical education classrooms in Seattle and Wyoming are not built for expansion of the WWAMI program by Wyoming and other states to accommodate more medical students making the quality of the education offered an issue. Rep. Iekel said the Legislature is prone to taking a snapshot of an issue when considering solutions and may not consider “the whole topography.

Rural Underserved Opportunities Program (RUOP) clerkships bring students into Wyoming communities where they are overseen by local practitioners who have to stay abreast of recent medical developments to supervise their protégés adequately. About 70 percent of the students are UW graduates. There is no program similar to WWAMI that is a regional medical school concept. Before Wyoming joined WWAMI, there was in place a contractual agreement that created opportunities for students in institutions in Utah and Nebraska. There are some other contract programs in operation -- Idaho participates in WWAMI and has some students enrolled at the University of Utah under a contractual agreement. But in Wyoming, WICHE and WWAMI work at cross purposes in recruiting, President Dubois said, because the repayment burden is lower with WICHE and there are no requirements to practice here after graduation.

Chairman Muirhead said the Commission could consider recommending a payback provision for WICHE, and separate state budgets or appropriations for WWAMI and the UW Family Practice sites. He asked President Dubois to list his five priorities for medical education. President Dubois said any program expansion should take into consideration program supply and distribution and be tailored to that goal. A WICHE payback provision will require consideration of the fact that WICHE tuition is lower than WWAMI’s and that WWAMI offers a comprehensive educational experience, in addition to making service in the state a requirement. Chairman Muirhead said he hopes the University and Commission can get ideas from the four states in WICHE with payback provisions. Sen. Scott said that a year or two ago, he would have agreed that physician distribution was as important as physician supply in Wyoming, but as physicians depart from their practices shortages are being created across the state. Dr. Fleming asked if Wyoming’s WWAMI program can include dental slots as is done in other states. The UW officials said there is discussion about expanding WWAMI to include dentistry but there are few students interested in that profession. By contrast, there are 10 applications per law school slot at UW. Commissioner Glode said that when mandating physician distribution, policymakers have to consider that some rural areas may not support a physician. He noted that a Cheyenne family practitioner recent closed his office after

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going broke. Quite frankly, some physicians are not making a very good living, Dr. Glode said.

Discussion followed regarding the Commission’s rural health study and its analysis of the availability of health care in the state. Sen. Scott said that the demographics of Wyoming are working against us as more and more residents become Medicare patients and physicians have greater difficulty making a practice profitable. Wyoming’s Medicare reimbursement is lower than in other, less prosperous states. Casper had a physician who retired early, an internist, who reported to the Legislature that his practice was 80 percent Medicare and he was getting squeezed between low reimbursement and the rising costs of medical malpractice insurance. The economics of a practice may not include patient volume, but payor mix. Patients whose coverage is provided by the government are having trouble finding doctors but it may not be profitable for docs to take Medicare and to some extent Medicaid patients, particularly in the area of family practice, the senator said. UW professor Jim Page, who is himself a physician, said his research shows that a family practice doc captures 4 percent to 5 percent of the economic benefit they provide to the community, and the state is going to have to look closely at that.

The rural health clinic system that Medicare has set up allows doctors to get cost-based reimbursement if they follow a certain set of rules. Project Coordinator Kruse said that in Niobrara County, the rural health clinic patient visit minimums are too high to support a clinic so that community (Lusk) has had to contract with Converse County Memorial Hospital in Douglas to pay a physician’s salary and provide coverage for Lusk. Dr. Fleming said that the Commission’s rural health study hopefully will determine what provider mix is needed and that information combined with the efforts of the Office of Rural Health and the Primary Care Association and UW to address provider shortages will provide some answers to this perplexing dilemma. She noted that Wyoming’s experience is similar to that in other rural states and we can learn from their experiences as well. Dr. Page said that the model that is frequently pushed upon frontier areas is a rural health clinic with a hospital providing salaried services with taxpayer support for the hospital. He said that you can view a physician as a private businessman but also equivalent to a firefighter or policeman who is always on call and not always paid for the care provided. Historically there have been public service components of the medical profession that were taken for granted when physicians made more money but they are now in a situation financially where the public can’t expect charity care to be part of the operating overhead of being a physician.

Wendy Curran, Director of the Wyoming Medical Society, said the physician viewpoint on medical education is that in the early 90s there was a very severe healthcare manpower shortage. A Memorandum of Understanding with WMS and UW was signed to allow the Medical Society to fulfill key roles in WWAMI. Three Wyoming physicians serve as the admissions committee for Wyoming students. WMS plays a role in the development of clinical training sites. A key to what makes a program successful is the participation of hospitals and physicians who continue to bring physicians back to the state to practice. When WWAMI was initially proposed with 10 Wyoming slots, the conventional wisdom was that we needed some time to see results before an increase in

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enrollment was proposed. Now that the first class has graduated from residency, there are a number of students who have come back to Wyoming and a number who stayed in the five other rural states participating in WWAMI. An increase of 12 to 15 is a good starting point for expansion, while18 is optimum and the same number as other states have enrolled. We believe that this program offers a huge benefit not only in training our students but also to physicians who already practice through clinical training sites. Physicians who feel isolated, overworked and overstressed have an opportunity to update their clinical skills and stay current while also training students. The program is structured to assure maintenance of the same level of curriculum and comprehension as all the other states. Wyoming physicians can call a toll free line and get their questions answered by the faculty at the University of Washington and can get continuing medical education credits under the WWAMI umbrella.

She noted that there was discussion about the potential for contracting with other, similar programs to allow more students from Wyoming to get medical education but she said that the policy decisions made in adopting our medical training through WWAMI were significant. Other institutions are have training components but none that say to medical students, “this is what it’s like to practice in a rural community and this is what you might find that you like.” Ms. Curran said that spending more money on recruiting and retention is shortsighted. “We can’t buy doctors. Taking the money for student slots and upping bonuses works only in the short term. It’s not necessarily an issue of how we spend the money but what we get in return. The residency programs are a key part of the training mechanism. The likelihood of physicians staying in a community are higher in the radius where they have completed their residencies.” She said that the Medical Society is concerned not only that fewer students are applying to medical school but also that fewer are choosing family practice. Funding for Wyoming residencies has remained level, making it difficult to recruit medical students back to the state. Recommendations the Medical Society would make would include looking at the WICHE program and consider the investment of the state in what it gets in return. We believe that now is a good time to increase WWAMI class sizes, she said, but that needs to be phased in. One of the concerns the admissions committee has is making sure you have a pool of applicants from Wyoming who have the MCAT scores to meet the stringent requirements of the University of Washington School of Medicine. We have been fortunate to have more applicants then there are slots but if we move too rapidly to increase class size in a diminishing pool of applicants, there is some concern we may not be able to do that.

UW’s classrooms can hold 12 and 15 comfortably but beyond that, policy decisions have to be made. Part of the message from the Legislature was not to create a barrier to enrollment in WWAMI that doesn’t need to be there. We need to figure out an appropriate number and make sure we have the conditions in place to train that number of students. Increased funding is needed for residencies to fend off quality problems and the ability of recruit the right set of residents for the state, Ms. Curran said. I think there is an opportunity for increased recruitment and coordination of recruitment with Wyoming Health Resources Network and the state residencies. We truly must broaden the discussion of medical education and rural health in this state beyond the University of Wyoming. UW has a key role but the policy decisions that go behind appropriate funding

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and growth of residencies and increases in WWAMI programs need to be broadened. There are others who have a role in strengthening the rural health system. There needs to be an advisory group, or the Healthcare Commission, to look at the policies behind whether program expansion strengthens our rural health care system, is that an appropriate way to go. Asking for a separate budget is appropriate. It’s difficult to ask the University to make accommodations in one component of its block grant when that will have to be weighed against other priorities. We in this room believe medical education is critical but I’m sure the pressure for different programs is there. Dr. Moore said Wyoming has up to five slots in the physician assistants program but we have never filled our full five. We’re usually running about two or three, partly because to quality a student is required to have experience in healthcare workforce before applying. Many of those who do apply are dietitians or nurses before they become physician assistants.

Commissioner Vandel, who is the University School of Pharmacy Dean, said that one possibility might be creation of physician districts that would mirror hospital districts in allowing people to pay a tax to retain healthcare providers in their communities. A selling point for that concept would be that a physician creates other incomes for the area. The state may need to help either fund or provide enabling legislation to form funding mechanisms for that concept. Ms. Curran said that the practice environment in Wyoming needs to be addressed, including medical liability problems and Medicaid reimbursement, to make Wyoming a place where family practice docs want to practice. We need lower liability premiums than are available in other states to make it a better financial opportunity for WWAMI students. Discussion initiated by Commissioner Mossbrook followed regarding mid-level training and education incentives.

Dr. Richard Hillman, Assistant Dean, WWAMI Clinical Phase, said that most of the states within WWAMI have programs to guide future prospective medical students so they do better and we don’t. We believe that’s one of the reasons they don’t do well on MCATs and we’re working with a number of our partners to develop a program. Dr. Fleming said students are attracted to a program based on the quality of the faculty. Word gets out regarding a program in decline or one that is considered top notch. Salary has a lot to do with candidates for faculty slots.

Sen. Scott said he is starting to think medical programs at UW need to be split out because of competitive salary costs and other rising expenses. In nursing, community colleges were notably more receptive to efforts to increase output than the University was, he said. We’re going to have to think that issue through very carefully. My guess is the next few years the political environment is going to be such that the Legislature is going to be receptive to spending more on healthcare professions. Since the state is experiencing increased revenues, that eases the burden. I think the majority of legislators are going to find back home that their people are having real difficulties obtaining adequate healthcare services. The problems vary from one location to the next. You can produce all the nurses you want and if Colorado pays better you are going to lose a lot of them. Because of the earning potential for physicians, you can take some off the back of the students in tuition paybacks but you get in trouble in the long term where the free

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market puts a much higher price on the services these people can perform than the normal University salary schedule.

Commissioner Vandel said that the School of Pharmacy can offer a faculty pharmacist $70,000 but in practice they can earn $105,000, so they have to want to teach to be available to be recruited. Commissioner Glode said the state is going to have to collect data out of the WWAMI program about physicians who come back and practice for three years and pay back loans to determine how many are going to stay. Right now, practices in other states are buying out loans to recruit physicians. Ms. Curran said that WMS can report what they find when interviewing exiting physicians. Dr. Page said trying to gather data is difficult and expensive when physicians are not reporting their whereabouts to an entity. He has been trying to do tracking on his own. Sen. Scott said that the people that like the lifestyle here can get the same kind of lifestyle in surrounding states with some control on the legal risks. I think it’s much more important to understand why people are not coming here rather than understanding why people are leaving. Dr. Glode said that unless we have this kind of data, how can we retain them? Young people are leaving, too.

Specialties are different, he said. Cardiology and general surgery are a true crisis in the making. Dr. Moore said that there are 77 students in the WWAMI pipeline who can be tracked until they exit the program. Commissioner Speight, a Cheyenne trial attorney, said he has sued and defended doctors and hospitals and believes more physicians should be elected to the Legislature to represent the issues impacting their profession. He cited a 2003 GAO report on medical malpractice insurance that states multiple factors have contributed to premium increases including patient safety and medical errors. He also cited a health grades quality study released by GAO in July 2004. He said he would like information on “horrendously shocking” numbers of deaths cited in the reports as attributable to medical errors. He said he represents several doctors who have left their practices in the last year or two in Cheyenne for reasons including medical malpractice premiums but that wasn’t at the top of the list.

When I hear the concepts the University is thinking about for how they compensate for all they do in rural communities I think this is a positive step, Commissioner Speight said. We all need doctors and damn good doctors and support staff in nurses and hospitals. We need to study why they leave or what it takes to get them back to make the best possible recommendations to the Legislature. Dr. Glode said you will not keep a physician who’s coming back to practice here only to pay back a loan. We don’t have data on how many WICHE students don’t come back to Wyoming, either. That’s why I call for prospective data when we start programs like this. Medicine is a changing landscape nationwide. If you look at the data around the country, physicians are coming and going all the time. We have to know what it takes to retain them. It’s not going to do us any good if 60 percent leave after they pay their loans back. WWAMI is open to all students and the emphasis is on making students comfortable practicing in a rural region, but WWAMI is training specialists, not just family practice docs. The University of Washington is highly ranked beyond primary care. Director Harrop said one other point is that patients’ expectations of their physicians may be outmoded. Where once the norm may have been that an indivudual would come to a community fresh out of residency and

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practice there until he or she retired, the practice of medicine in today’s world has changed and physicians, like everyone else, are often much more mobile. Commission Glode said that Commissioner Lang’s healthcare access subcommittee holds the key the development of a rural healthcare network and his work includes all these questions including recruitment and retention.

Dr. Hillman said he is employed by University of Washington representing Wyoming. We have a person in my position in each of the five states in the WWAMI region and in Dr. Moore’s position. One of the big things that’s happened is that I’ve just increased my time. It’s allowed us to build on the partnerships. Our goal is to work as partners to make this a better program for Wyoming. The WWAMI program is really a premier health and medical education program for regional purposes in the United States. The University of Washington ranks highly in primary care, research, and specialties. Twelve to 15 students can be enrolled; we do have some classroom size problems but can adjust. The WWAMI program has several phases. In each WWAMI state, the first year of medical school is completed at home. The second year is spent in Seattle. The clinical phase is the third and fourth years of medical school. Students can go to any of the five states. We can have students coming to Sheridan to the VA who grew up in Seattle. Wyoming students are given priority but other states’ students come as well. One of my biggest problems is getting new clinical clerkship sites approved by the University of Washington in Wyoming because they have more than enough sites for the students. Practices are compensated a small amount for hosting clerkships. Communities work closely with hospitals and the Hospital Association to provide housing for residents. In one community, the students get health club memberships. It’s turned into an interesting competition to get these clerkship sites. During their integrated training experience, students spend 20 weeks in a rural site doing primary care in family and internal medicine, pediatrics and psychiatry. Only 10 students are accepted; 25 to 30 students apply. This is an excellent program for those students interested in primary care. It is also excellent to orient students not interested in primary care to rural environments. The residency program is the students’ last stage. The advantages of WWAMI are that we are dealing with an excellent medical school. That doesn’t mean we shouldn’t work with WICHE --we should promote that as well. But WWAMI is a great opportunity for us because of its emphasis on primary care and rural medicine. They teach specialists what it is like to practice medicine in a rural environment. Last of all, the WWAMI program has an excellent return rate to the WWAMI region (much greater than 70 percent).

WWAMI also assisted Wyoming with looking at how to maintain hospitals and brought in facilitators to engage the community in a community capacity building process. People were hired to be champions and those communities continue to get WWAMI support. Dr. Fleming talked about adding weekend social visits for medical students to spend time getting to know communities outside of work, a program considered by the CHC in Casper. The next phase would have been some sort of mentoring program with retired physicians, which holds promise even with WICHE students. Wyoming students have had a complete success rate on their family practice boards. A female Wyoming student was the top scorer in the University of Washington on her part I exams. Those who graduate, pass, Dr. Moore said. Dealing with students in clerkship settings is a benefit for

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physicians and students. Students are required to do projects based on community needs, such as exercise programs, followup clinics for diabetics, and so on. They become part of those communities.

Laramie Downtown Clinic

Rep. Lorna Johnson, Director of the Downtown Clinic in Laramie, Dr. Paul Ogden, an emergency room physician at Ivinson Memorial Hospital in Laramie, and Kendra Grande from the UW School of Pharmacy, presented the opportunities and challenges of free clinics (handout, Downtown Clinic.pdf). Dr. Ogden has been with the Downtown Clinic since 1999 when he began serving there as a monthly volunteer and a board member. Ms. Grande is a volunteer pharmacist at the clinic and also a member of the board of directors. The clinic was formed in 1999. The clinic’s mission is to provide non-emergent primary healthcare to low income uninsured residents who have no access to healthcare due to their financial means (185% of poverty or below). The clinic does not serve people on Medicaid or Medicare, veterans, UW or local tech school students, or children. If parents qualify for clinic care, their children qualify for state health insurance coverage and enrollment forms are provided. The clinic is only open Wednesdays from 4 to 8 p.m. Patients are treated on a first come, first served basis. The clinic offers integrated healthcare -- primary care, nursing, pharmacy, mental health, case management. A part-time staff coordinates 65 volunteers; it takes10 volunteers per week to keep the clinic doors open. Two primary care providers are on duty, with one nurse, one pharmacist and one pharmacy tech, and a social worker. Students in nursing, pharmacy, social work, and mental health rotate through the clinic every two weeks. The only staff is the director, patient care coordinator and a part-time family nurse practitioner who assists with continuity of care and gives extra attention to a select few clients with multiple chronic illnesses. The three positions do not total one FTE.

The clinic has no intention of increasing its hours or changing its mission but is offering different services to facilitate its mission to a further extent, like a prescription drug refill clinic on Tuesdays from 4 to 6 p.m. There are other types of providers from the community who want to help and are accommodated, like a podiatrist who offers free diabetic foot care. Volunteers donate 4,000 hours per year. The clinic sees up to 45 clients in one night, although the average is 34 and the director’s goal is to get volunteers out by as close to 8 p.m. as possible. The per client visit cost is $18.08, including prescriptions; $85,000 worth of health care is donated. The clinic has more than 1,500 clients ranging in age from 18 to 65 years of age on the rolls and about 500 acute and chronic patients are cared for annually. Sixty-three percent are women. Many are single heads of household. Many are employed. The clinic’s strength is the generosity of the people.

The clinic’s $90,000 annual budget is funded with private donations, small grants, and United Way allocations. The primary clinic supports are public health nursing, Ivinson Memorial Hospital, a medical laboratory and the University of Wyoming College of Health Sciences. The clinic also gets Community Service Block Grant money. The issues that arise include medical care needs of a woman with three children who has cancer and

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who will pay for her treatment if she can, whether a small town like Laramie can maintain the care provided at the clinic, and what about other small towns? When the need becomes greater than who we are, then what happens? The number of people seeking care is increasing.

Dr. Ogden said he is a Wyoming native who grew up in Cheyenne, went to Creighton University in Nebraska and did his residency in Casper with the UW Family Practice Residency Program. He is an emergency room physician who has practiced 11 of 12 years in Laramie (he spent one year on an island in Alaska). His roles at clinic are board member (since before the clinic started) and volunteer. He described his typical experience with a patient. Physician liability is covered by the individual providers’ policies. We haven’t been challenged. The hope is that the clinic would have little to go after so it wouldn’t be an attractive target. The clinic itself carries no specific insurance. His UMIA premium didn’t increase for doing free clinic work. There are no retired or University physicians volunteering at the clinic because they don’t have private malpractice insurance so it does limit us in who can be our providers. Volunteer health practitioners are required to carry insurance to work at the clinic. Discussion followed regarding liability waivers, and Commissioner Speight volunteered to assist the clinic with setting up that system free of charge. WMS Director Curran said legislation was passed by the state Legislature that provides immunity for free clinics in the state but it does not apply to the clinic in Laramie because to be eligible, free clinics must carry a $1 million liability policy.

Dr. Ogden said that he is not familiar with many of the drugs and their interactions his free clinic patients need since his regular practice is in the hospital emergency room, so he gets assistance from volunteer pharmacists. Physicians don’t have that luxury, working in the office. Psychologists and social workers are available to the patients. Providers may be dumping difficult chronic patients with illnesses like pain management they might have carried in the past on the clinic. The hospital has been supportive of free clinic patients and treats them as part of its indigent care responsibilities. Referrals made out of town to specialists, like an endocrinologist or rheumatologist, are accompanied by a request for donation of the needed care. We’ve tried to solve a national problem at the local level, Dr. Ogden said. The needs that are not being met with our lack of a national healthcare system are being addressed in Laramie through some small efforts and we’ve been successful within a limited realm and a small group of patients. In reality I don’t think this can be extended to other low income people who are just above our range or in communities where they don’t have the resources we do. If it were not for the University and the hospital, it would be extremely difficult to make ends meet.

Ms. Grande grew up in Casper and got her pharmacy degree at UW. She now works for the College of Health Sciences School of Pharmacy, running the drug information center. She serves on the free clinic board and as a volunteer pharmacist. The Downtown Clinic is committed to providing medications to patients – it is difficult to provide healthcare without medications. The use a formulary rooted in “tried and true” generic medicines. There are times when they have to stray outside of the formulary but the clinic volunteers work hard to tap into drug manufacturer assistance programs to provide medications at no

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cost to patients. There are significant limitations to the manufacturer assistance programs because they require lots of paperwork and drugs are slow to arrive, resulting in gaps in treatment. Pharmacists try not to use samples because the supply is unreliable. They use samples for acute conditions, like when they need antibiotics to treat a serious dog bite or something that requires a high-powered antibiotic. There’s a role for manufacturer assistance. Pharmacy is the largest part of the downtown clinic budget – we’re always blowing our budget. Pharmaceuticals cost the clinic $26,000 plus last year. They fill an average of 70 prescriptions per week. They train patients on the use of glucose monitors and blood pressure cuffs for home use and provide those. The UW pharmacy faculty has been joined by Jennifer Petrie, who is developing clinics on specific diseases, like cardiovascular disease with a clinic addressing hypertension, and a women’s health clinic checking bone density, a clinic on smoking cessation. Of the clinic’s total budget, one-third is pharmacy. Many clinic patients are people working multiple part time jobs who are able to stay in within their budgets until a medical crisis hits.

Discussion followed regarding the cost of care per patient and the amount of clinic resources invested in fundraising. Commissioner Jenkins noted she had just gotten a postcard from former Commissioner Dr. Robert Volz in Jackson announcing that a fun run fundraiser would soon be held for the free clinic he helped launch in his community. The postcard notes that there have been 500 patient visits at the Jackson free clinic in the last six months, reducing the volume and cost of charity care in the community. Cheyenne has a free clinic. Sheridan is working toward creation of a free clinic, Ms. Johnson said. The Laramie clinic is at maximum patient load. Ms. Johnson, who is a state representative, said she thinks it would be better to fund admission of adults into the state’s SCHIP program to give people access to the healthcare delivery system, and take pressure off of the free clinic.

Committee reports

Commissioner Lang, Chairman of the Healthcare Access and Affordability Subcommittee, reported that the proposed Memorandum of Understanding with the Department of Health to transfer funds and share results of the Rural Health Study has been discarded after a lengthy discussion with the Office of Rural Health. The Commission and SORH will conduct their research projects independently, by mutual agreement. The first deliverable received from Rural Health Study consultant Navigant arrived the week of Aug. 13 and represents the start of the Wyoming specific definitions for urban, rural, and frontier. Navigant has proposed a two-pronged approach: (1) Maintain the federal definitions required to qualify for federal programs which use a broad brush that divides the state between metropolitan areas (Casper and Cheyenne) and not metropolitan areas; (2) Based on community size, what services should a given community of a given size have available in that community, and what is a reasonable distance to go to get to health services. This concept is fairly involved and consumed a good bit of discussion. A survey is being written to determine what access issues to include. The information gathered will assist in determining the state’s position in developing priorities for different types of services. The study will look at regionalization

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and who drops out of the state for care and who doesn’t. Discussion followed regarding the impacts of weather and topography on access to care during the winter.

Commissioner Glode talked about the hazards of using superficial modeling developed by using demographics without community-specific analysis. He said Bill Lindsay, former promoter of WIN Healthcare in Wyoming, did site-specific community demographics successfully while another consultant the hospital in Cheyenne hired to make recommendations on cardiology relied on the Internet and came up with faulty recommendations. He advised against using a “cookie cutter” formula rather than site-specific recommendations using Wyoming data. We need to be tracking people who leave the state for care who are not funded by Medicare or Medicaid. If wanting to ascertain where to place family practice physicians, one must have site specific data that will support a case for why it won’t work in Buffalo to add a family practice doc. At the end of the day, do we get a model delivered to the Commission that can help us create a rural healthcare network including where we refer our patients to, Commissioner Glode asked. I don’t know whether you think we’re going to get that.

Part of the healthcare network is going to have to be WYO CARE. When you send patients out of state, it costs you a lot of money. All the dollars you can keep in your network keeps the network more affordable. You can afford to buy more MRIs if more MRI patients stay in Wyoming, Commissioner Glode said. The problem with consultants is they come in and then leave you with a big book and walk away. There’s no facilitator, no locally-based guide. He suggested the Commission ask the Legislature for more time to complete the Rural Health Study, slated now to be completed in October. I’d rather have a late report that’s accurate and doable, he said. The questions surrounding healthcare manpower needs cannot be answered without the study, he said. Director Harrop noted this is not a study with a legislative deadline. Navigant is going to need a lot more guidance. How would they know that it is economically viable for Dr. Glode to drive from Cheyenne to Rawlins to operate a cardiology clinic? A consultant his firm used to help determine his practice’s market area threw Scottsbluff in to the total as 30 percent of the population and told them to recruit a certain number of cardiologists based on that – but Scottsbluff was already working toward partnering with Colorado. That consultant just drew a circle on a map. Those are the kinds of mistakes consultants can lead you to, he said.

Commissioner Roberts, Chairman of the Medical Errors and Patient Safety Subcommittee, said assistance will be provided on the study by the Department of Health’s Fran Cadez. Ms. Cadez is an attorney who received master’s degree in health administration and who also worked on the creation of the worker’s comp Medical Commission. There is no United States model for medical errors but she and Commissioner Glode have come across studies from New Zealand and Switzerland. Their research is three pronged: they want to look at which healthcare errors are cognitive, which are physician errors, errors in judgment; secondly, systemic errors and the cost of the proposed commission system in comparison to what exists; and development of a patient safety format. Commissioner Glode said that they are in the process of reading materials and books about the subject. There has been no medical

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errors commission in the United States but Sweden and New Zealand have them and they have been studied. Commissioner Speight, who is also working with Commissioners Roberts and Glode on medical errors, said a report in July 2004 concluded there are preventable medical errors causing hundreds of thousands of deaths annually. He cited the source as a legitimate evaluation company that can grade and evaluate hospitals and medical doctors by specialty, but noted this is the third study since 1998 on patient safety with the same findings. He thinks the magnitude of the medical errors problem is underestimated.

Medical Liability and Uncompensated Healthcare Subcommittee Chairman Muirhead said that the month of August was filled with trying to contract for three studies. Those studies will analyze, as legislatively mandated, the possibilities of an excess liability fund, a risk retention fund, and the impact of non-economic damages caps set at $250,000, $350,000, $500,000 and $1 million. Eight firms were contacted during the last month based on the referrals of the Wyoming Insurance Commissioner, the Wyoming Trial Lawyers Association, the Wyoming Medical Society, and a group of Wyoming physicians interested in setting up a risk retention group. Six different firms submitted 17 proposals. Five of those submitted proposals to do all three studies. Each of the six firms were interviewed for an hour by Insurance Commissioner Vines and Director Harrop, who did independent evaluations before discussing their top choices with each other. Their recommendation, brought to the subcommittee, resulted in a decision to begin negotiations with Milliman, Inc. to do all three studies. Later this week the Commission will sign a contract with that firm. The lead consultant from Milliman will be in Cheyenne to meet with subcommittee members, Commissioner Vines and Director Harrop on Tuesday, August 31.

Former Commissioner and Rock Springs lawyer Ford Bussart was going to look at professional licensure statutes for physicians, physician assistants, dentists and other health professionals to determine whether there are barriers in licensing statutes that inhibit appropriate immigration of medical providers. The decision was made to place an advertisement with the UW Law School to see if there was a second or third year law student willing to do the analysis for $3,000 to $5,000. Discussion followed about how to determine all the possible barriers with just a statutory review. Chairman Muirhead said he is open to ideas on how to reach an understanding of what stands in the way of the migration of healthcare providers into the state, including reciprocity, and non-acceptance of course credits. I don’t know how you do this without an audit. It was suggested that those who are hiring medical professionals be surveyed to find out who they haven’t been able to bring in and why. Commissioner Speight said he has represented a nurse, a chiropractor and a psychologist who were getting jerked around and the study needs someone who understands administrative law. The analysis won’t just look at the statutes but also the formal board rules and regulations associated with each medical profession’s licensure. Dr. Fleming said when she was working at the CHC in Casper, they ran into problems with the Dental Board. A job announcement was placed on the UW Law School web site encouraging law students to submit a bid for work on this study. There have been some responses and the deadline for bids is September 1. The Commission is not looking for a student who will do the whole analysis but will give us a good starting

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point. Senator Scott said the information that is gathered can be used to send a message to the Legislature’s management audit team with a request to do an analysis of professions where there’s the most problem and the most impact.

The Uncompensated Catastrophic and Trauma Care Study update was provided by Assistant Director Genoff (handout, Uncompensated Care.doc). Surveys have been sent to 20 Wyoming hospitals to determine the impact of uncompensated catastrophic and trauma care at facilities of all sizes with all levels of care. The consultants also are gathering information from other states about the types of funding streams being used to cover the cost of uncompensated care and assure the financial viability of rural health delivery networks.

Commissioner Jenkins, Chairman of the Healthcare Information Technology and Disease Management Subcommittee, said Enrolled Act 31, the Legislatively-mandated information technology study, is progressing. A request for proposals was released July 1. Since then, the IT2 Committee working on the study has received 36 written questions from potential proposers, most of which were more process than content-oriented. The questions, responses and two amendments to the RFP went out to the potential proposers. The format for final selections of vendors was developed by the IT2 Committee, which has decided the finalists will be narrowed to a list of the top three based on technical proposals. The IT2 Committee is in the process of choosing its proposal evaluators and creating its scoring mechanisms. Selection of a contractor will be completed by Oct. 1. The first face- to-face meeting with the selected firm is planned for Oct. 16.

The Health Record Network (formerly known as HDx) project is moving along. Corporate sponsors are being solicited.

The subcommittee’s disease prevention focus has been on tobacco use and obesity. Last month, the Johnson County tobacco control program manager spoke to them about primary care guidelines for tobacco cessation and nicotine replacement. She has had success working with physicians and getting referrals from primary care offices into the nicotine replacement and tobacco cessation program. She and the Community Resource Center in Johnson County are looking at working on a statewide implementation of primary care screening and intervention guidelines. Under the guidelines, a physician asks patients if they are using tobacco and makes an intervention prescription when appropriate. The subcommittee focused on tobacco use because in 1999 in Wyoming there were 729 premature deaths and $106 million was spent on smoking-related healthcare costs. Of that, $11 million was Medicaid money. Twenty-three percent of Wyomingites smoke and 8.7 percent use spit tobacco. Twenty-six percent of high school students smoked and 13.3 percent used spit tobacco, according to the Youth Risk Behavior Survey conducted in Wyoming schools. There has been success in diminishing access to tobacco through enforcement of tobacco laws and a higher cigarette tax. Obesity is a behavioral issue that the Centers for Disease Control in Atlanta are looking at addressing similarly to tobacco with multi-dimensional approaches. The subcommittee will be meeting with Janet Jares, Wyoming Department of Health Tobacco Use Prevention Coordinator, and Sunny Kaste, Department of Education At-Risk and School

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Health Programs Supervisor. Discussion followed regarding state corrections system inmate tobacco use.

Commissioner Bryce, Affordable Healthcare Coverage Subcommittee chair, said that on Aug. 31 and Sept. 1 his group will host a special session in Cheyenne to talk about the cost of healthcare. If we don’t figure out something to control the cost of healthcare, ergo the cost of insurance to cover the cost of healthcare, it is not going to do much good to expand healthcare coverage. Doctors, hospitals, Medicare, Medicaid, insurance companies, and Bill Lindsay will be part of this 24-hour session. Mr. Lindsay is the person Commissioner Glode mentioned helped out eight years ago in coming up with a statewide plan for a PPO (WIN Health) and has been through it before. As facilitator, he will be able to lead the group with what he learned from that process. We needed some sort of place where we ask everyone to take off their gloves and come together at a round table. We begin at 2 p.m. Tuesday and will have a lot of creative people who call Wyoming home in the same room. Mr. Lindsay will get a discussion going and whether their result is some sort of specific Wyoming PPO, or whether it’s the beginning of a purchasing coop, we don’t know. The Department of Employment will report their findings regarding employers and health benefits, and their attitudes toward group insurance and what needs to be done to help make it work better. The subcommittee and staff will meet with Linda O’Grady, Senior Health Policy Analyst in the Wyoming Office of Medicaid, on Sept. 17 to assess potential expansion of that program based on the findings of a consultant’s study. Debit card claims administration of WYO CARE is being studied by Steve Manley and that will be discussed at the Aug. 31-Sept. 1 session, as well. What if insurers determine that Wyoming doesn’t amount to much and they don’t want to be in our market? If that’s their attitude, we’ll do fine with Blue Cross and WIN Health. Hopefully in the same room with a friendly atmosphere we can get the ball rolling. We’ve gotten along without Cigna and Great West being in the small group market. If we have to get along without them, we can build a system that will work -- but competition with choices of plans is better. Our goal is to have it be attractive enough that the free enterprise system will work without the “m” (mandatory) word, Commissioner Bryce said.

Preview of an Educational Powerpoint presentation for Constitutional Amendments C and D

Commissioners reviewed the presentation the WHCC was asked by the League of Women Voters to make available as an educational tool about the Wyoming Healthcare Commission and it’s recommendation concerning Constitutional Amendments C and D which will appear on the November 2 general election ballot. The Commission recommended to the Legislature that legislation be passed to allow Wyoming voters to make final decisions on these two issues.

Constitutional Amendment C will read as follows:

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This amendment would allow the Wyoming legislature to enact laws requiring alternative dispute resolution or medical panel review before a person files a lawsuit against a health care provider for injury or death.

Constitutional Amendment D will read as follows:

This amendment would allow the Wyoming legislature to enact laws limiting the amount of damages for noneconomic loss that could be awarded for injury or death caused by a health care provider. "Noneconomic loss" generally includes, but is not limited to, losses such as pain and suffering, inconvenience, mental anguish, loss of capacity for enjoyment of life, loss of consortium, and other losses the claimant is entitled to recover as damages under general law.

Many changes to the Powerpoint were discussed, including dropping the American Medical Association’s map of states classified as a “crisis” due to medical malpractice insurance costs and availability. Commissioner Speight was opposed to including the map and wanted all dissenting perspectives explained. Commission members decided to keep the map itself in the presentation since it has been so widely publicized that most all physicians considering coming to Wyoming have probably seen it. The Commission also decided to include information about its own final recommendations and conclusions, and not attempt to summarize the positions of the various advocacy groups. The Powerpoint presentation will be given final consideration by the Medical Liability subcommittee before being released.

Meeting adjourned

*NOTE: To obtain handouts, please go to the Wyoming Healthcare Commission web site search box and type in the handout name as cited above. Or, if a hard copy is preferred, please call the Wyoming Healthcare Commission office, (307) 235-3227.

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