Department of Health and Human Services
Nevada State Health Division
Presentation to the Assembly Committee on Health and Human Services J-1 Visa Waiver Program for Foreign-born Physicians
Expanding Access to Primary Care
The Mission of the Health Division is to Promote and Protect the Wellbeing of Nevadans and Visitors to our State by Preventing Disease, Injury and Disability
Jim Gibbons, Governor Michael J. Willden, Director Richard Whitley, MS, Administrator Mary Guinan, MD, PhD, State Health Officer
Lynn O’Mara, MBA, Health Planning Program O’ Manager Christine Roden, RN, MPH, Manager, Primary Care Office
Nevada State Health Division
J-1 Visa for Non-immigrants
♦ Administered by federal Department of State and Department of Homeland Security’s U.S. Citizenship and Immigration Services (USCIS) Allows an international medical graduate to come to the US under an educational exchange program for up to seven years Upon expiration, the physician must return to his/her own country for at least two years before applying for a permanent US visa Categories: Physicians, Professor & Research Scholar, Trainee, International Visitor, Government Visitor, College & University Student, and Short-Term Scholar
May 6, 2009 Assembly Committee on Health and Human Services
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Nevada State Health Division
J-1 Visa Waiver
♦ Eliminates the two-year home/foreign residency requirement ♦ Allows the physician to remain and practice in the US, in primary care, providing access to health care services in medically underserved rural and urban communities ♦ Request by a designated state health agency or its equivalent – one of five statutory basis permitting waiver of the two-year foreign residency requirement ♦ Exempt from H1-B visa cap ♦ Can be applied to specialists, if the sponsoring agency can demonstrate the area to be served has a shortage of the particular specialty ♦ Displacement of an American-born physician is prohibited
May 6, 2009 Assembly Committee on Health and Human Services
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Nevada State Health Division
Conrad State 30 Program
♦ Allows state health agencies to request up to 30 J-1 Visa Waivers per federal fiscal year ♦ An important source of qualified physicians for medically underserved rural and urban communities – part of the state’s health care safety net ♦ Requirements
● Full-time offer of employment (40 hours per week) as a primary care physician in a federally-designated medically underserved area in the state ● Letter of support from the designated state health agency official supporting the J-1 Visa Waiver application ● 3-year employment contract
May 6, 2009 Assembly Committee on Health and Human Services
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Nevada State Health Division
Program Problems
♦ Mid-1990s: Primary Care Development Center (PCDC), including J-1 Physician Visa Waiver Program, Midtransferred from Health Planning to Family Health Services, for personnel reasons ♦ Sometime 2001-02: Historic oversight by State Board of Health ceased for reasons unknown 2001♦ September 2007 – January 2008: Las Vegas Sun “Indentured Doctors” investigation published, detailing program problems and deficiencies ♦ October 31, 2007: Health Division first status report about J-1 Physician Visa Waiver Program presented to interim Legislative Committee on Health Care ♦ December 14, 2007: J-1 Physician Visa Waiver Program public meeting held to discuss proposed changes to program guidelines and to obtain feedback regarding physician recruitment and retention ♦ Late December 2007 – Early January 2008: Health Division explores restoring the PCDC to Health Planning Unit ♦ January 14, 2008: PCDC restoration to Health Planning Unit and renamed Primary Care Office (PCO), consistent with other states ♦ April 11, 2008: First meeting of the Health Division Primary Care Advisory Council, piloting new, transparent application review process
May 6, 2009
Assembly Committee on Health and Human Services
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Nevada State Health Division
Health Division Primary Care Advisory Council
♦ Mission – To examine, consider, and make recommendations about the following issues:
● J-1 Physician Visa Waiver applications, in accordance with 8 USC 1184(214)(k) and Title 22 CFR 41.63 ● J-1 Visa Waiver Employer Site Visits review ● J-1 Physician Visa Waiver program complaints ● J-1 Physician Visa Waiver program policies and procedures ● Primary care development activities, efforts and initiatives ● Primary care provider recruitment and retention efforts ● Other issues impacting primary care access, availability and utilization
May 6, 2009 Assembly Committee on Health and Human Services
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Nevada State Health Division
Health Division Primary Care Advisory Council
♦ Seven volunteer representatives from a variety of organizations and stakeholders in the private and public sector that have impact on the provision of primary care within Nevada, particularly in medically underserved areas Members appointed by the Health Division Administrator for a two-year term Recommendations of the Council are advisory only First meeting held April 2008 and bylaws adopted June 2008 Meets at least quarterly – met five times during calendar 2008 Follows Open Meeting Law
May 6, 2009 Assembly Committee on Health and Human Services
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Nevada State Health Division
Health Division Primary Care Advisory Council
♦ Members
● Gabriel Bonnet, MD, Retired Pediatrician/Neonatologist and former Medical Director for Renown Health, Reno, NV ● Senator Maggie Carlton – Community Development Director, Great Basin Primary Care Association, Las Vegas, NV ● Caroline Ford, MPH – Vice Chairperson, Assistant Dean/Director, Center for Education and Health Services Outreach, University of Nevada School of Medicine, Reno, NV ● Carl Heard, MD – Chief Medical Officer, Nevada Health Centers, Inc., Carson City, NV ● Lawrence P. Matheis – Executive Director, Nevada State Medical Association, Las Vegas, NV ● Amir Z. Qureshi, MD – Chairman and Infectious Diseases Specialist, Las Vegas, NV (former J-1 Visa Waiver physician) ● Charles Duarte – Administrator, Nevada Division of Health Care Financing and Policy, Carson City, NV
May 6, 2009 Assembly Committee on Health and Human Services
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Nevada State Health Division
Current Status of Nevada’s J-1 Visa Waiver Program
♦ All applications and provider modifications are being reviewed by the Primary Care Advisory Council and approved by the Health Division Administrator ♦ Procedures have been developed for addressing complaints and violations ♦ Program Policies and Procedures reviewed publicly twice and anticipated to be finalized July 2009 ♦ Unannounced comprehensive site visits for assessing compliance ● 88% of annual visits have been completed – 41 physicians and 26 employers ● Only 29% (6/21) were in compliance with federal and state requirements ● 7 of 41 physicians were not at the site designated on their H-1B Visa, as required by Immigration and by the program ● One site remains non-compliant, and the PCO is assisting the physician with finding a new employer
♦ Collaboration with the State Board of Medical Examiners to resolve bottlenecks, from receipt of an application
● Start to work time has gone from 150 days to less than 60 days ● Board staff attending Council meetings ● Board staff has provided education and guidance regarding the licensing and complaint investigation processes
May 6, 2009
Assembly Committee on Health and Human Services
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Nevada State Health Division
Current Status of Nevada’s J-1 Visa Waiver Program (continued) ♦ Primary Care Office Management
● Contractor hired actively recruit residents from all professionals schools, and to develop recruiting materials ● Anticipates filling ten Conrad 30 slots during federal fiscal year 2009, fifteen for 2010, and twenty for 2011 – the goal is to fill all 30 slots ● Contacts have been established with Immigration to report/discuss issues ● Over 200 curriculum vitae for physicians and other health care practitioners were shared with safety net providers, during FY 2008 ● An orientation program is in development, for physicians, employers and immigration attorneys, to correct a key program deficiency ● Facilitating the quarterly meetings of the Primary Care Work Group of stakeholders involved with access to care issues ● Collaboration initiated with Division of Health Care Financing and Policy, for better J-1 Visa Waiver program tracking and management and needs assessments
May 6, 2009 Assembly Committee on Health and Human Services
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Nevada State Health Division
Program Review and Analysis
♦ Complaints received prior to January 2008 went unaddressed, leading to critical program deficiencies, J-12 Visa physician abuse, and decreased participation Lack of transparency and oversight, with ambiguous ability to enforce federal rules No collaboration between the PCO and key state and federal agencies Lack of detailed evaluation of applications, including employment contracts, to ensure compliance with federal rules and support of the spirit of the program Annual site visits not being done Inconsistent tracking of J-1 Visa Waiver physicians, after H-1B status received De facto program policies and procedures, with reliance on federal program guidelines that were somewhat vague Employers, J-1 Visa physicians, and immigration attorneys ignorant of or confused about program rules and requirements
May 6, 2009 Assembly Committee on Health and Human Services
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Nevada State Health Division
Comparison With Other States
♦ Only Nevada
● Employing a transparent process to review applications ● Utilizing Medicaid billing data to ensure that J-1 Visa Waiver physicians are providing medical services to the underserved ● Acknowledging and balancing the rights and responsibilities of both the employers and physicians with the program rules ● Issuing letters of deficiency, requiring corrective action plans, and re-visiting sites with critical deficiencies
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While Nevada’s problems are not unique, other states have been hesitant to acknowledge similar or related problems Fourteen states have enacted statutes and/or regulations, chiefly to establish minimum state requirements and enable some rules enforcement
May 6, 2009 Assembly Committee on Health and Human Services
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Nevada State Health Division
Where to go from here…
♦ Problem: While all non-legislative actions have been taken, these are not sufficient to properly support the program and improve access to care in the long term. Solution: Legislation has been requested by the Health Division Primary Care Advisory Council to enable the State Board of Health to adopt regulations to formally establish and enforce program requirements. Problem: Lack of fiscal resources limits the ability of the Health Division to effectively manage the program. Solution: Like seven other states have done, permitting the Health Division to collect a modest application fee would allow some cost recovery for program compliance activities.
May 6, 2009 Assembly Committee on Health and Human Services
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Nevada State Health Division
Recommendations for the J-1 Visa Waiver Program for Foreign-born Physicians POLICY AND PROCEDURES, REGULATIONS AND STATUTES
Issues: Lack of Oversight and Transparency
April 2009
Program and Policy Changes: Health Division Seven volunteer leaders from a variety of organizations and stakeholders in the private and public sectors who have impact on the provision of primary care in Nevada, particularly in medically underserved areas, were appointed by the Health Division Administrator to serve on the Health Division Primary Care Advisory Council. No other state seems to have a transparent process for approving J-1 Visa Waiver applications. Health Division Primary Care Advisory Council meets at least quarterly, follows Open Meeting Law, and examines, considers and makes advisory recommendations to the Health Division Administrator regarding primary care issues, including the applications for J-1 Visa Waivers. State Attorney General is represented at Council meetings. Procedures developed for addressing complaints and violations. Unannounced comprehensive site visits now being done annually, with return site visits for follow-up of critical deficiencies. Program review and analysis done, with referrals of issues and complaints to the State Board of Medical Examiners, State Attorney General, US Immigration, and US Department of Labor. State Board of Medical Examiners provided education to the Council regarding its complaint investigation process and provided guidance on typical program complaint scenarios. Primary Care Office staff have met or spoken with 82% of the current J-1 Visa Waiver physicians. Web-based complaint system is available. Collaboration with State Board of Medical Examiners, from the time a J-1 Visa Waiver application is received, has resulted in an improvement of start to work time from 150 days to less than 60 days. Board staff attend Council meetings and have provided education on the licensing process. Unannounced comprehensive site visits are being done, with revisits as necessary. Medicaid billing data is being monitored to establish that the sites are providing primary care to underserved communities, and to ensure that the J-1 Visa physician is providing service at the designated work site. Current and past J-1 Visa Waiver employment contracts are being reviewed for program compliance. Seven contracts have been amended to meet the program rules. After review by the Attorney General’s Office, deficiency letters have been sent to approximately 71% of employers found not to be in compliance with program rules. Written plans for corrections were received in all cases.
Complaints
Medical Licensing Bottlenecks
Lack of Employer / Physician Compliance
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Nevada State Health Division
Recommendations for the J-1 Visa Waiver Program for Foreign-born Physicians POLICY AND PROCEDURES, REGULATIONS AND STATUTES
Issues: Lack of Employer / Physician Compliance (continued) Lack of Formal Program Policies and Procedures Lack of Program Management
April 2009
Program and Policy Changes: Health Division During site visits, emphasis is placed on objective evidence of compliance, such as appointment lists and availability, wages, benefits, bonuses, moving expenses, direct service hours, and staff feedback on provision of care to the underserved and the site’s sliding fee scale policy and posting. Draft policies and procedures have been reviewed twice publicly. They are anticipated to be finalized by July 2009. Performance indicators have been developed. Tracking required semi-annual reports and verify the information provided. Tracking status of physicians from receipt of H-1B visa status through completion of commitment. Improved identification and tracking of federal designations and re-designations for Health Professional Shortage Areas (HPSAs). Employer and Physician satisfaction surveys were conducted and analyzed , and will be repeated annually. Exit interview developed and will be used with first eligible physician. Actively recruiting more J-1 Visa Waiver employer sites, and post their job vacancies on our web site. Approximately 200 curriculum vitae, received by the Primary Care Office, are distributed to J-1 Visa employers annually. Facilitating quarterly meetings of the Primary Care Work Group of stakeholders who are involved with access to care issues. Relationship and collaboration re-established with the state’s Primary Care Association (Great Basin Primary Care Association) to address and improve access to health care for underserved communities and to support the safety net.
Issues: Non-compliance with Federal and State Requirements
Regulations: State Board of Health Legislation was requested by the Primary Care Advisory Council to enable the State Board of Health to adopt regulations to formally establish and enforce program requirements. The Health Division briefed the State Board of Health about the program, its issues, and the corrective actions taken. The Board is aware that it may be authorized to adopt necessary regulations, per pending legislation. Federal and state requirements can be clarified through the administrative rulemaking process.
Ambiguity of Federal Regulations
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Nevada State Health Division
Recommendations for the J-1 Visa Waiver Program for Foreign-born Physicians POLICY AND PROCEDURES, REGULATIONS AND STATUTES
Issues: Program Non-compliance
April 2009
Senate Bill 229: Enhancing Health Division Authority for the J-1 Visa Waiver Program The Health Division testified to the 2007-2008 interim Legislative Committee on Health Care and to its Subcommittee to Review Laws Concerning Providers of Health Care, the Use of Lasers, Intense Pulsed Light Therapy, and Injections of Cosmetic Substances that legislation may be necessary to ensure compliance with federal and state requirements. The Health Division Primary Care Advisory Council determined that while all non-legislative corrective actions have been taken, these would not be sufficient to properly support the program and improve access to care in the long term. Council member Senator Carlton volunteered to sponsor the needed legislation. Current available fiscal resources limit the ability of the Primary Care Office to effectively manage the program.
Limited Funding for Program Management
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J-1 VISA WAIVER PROGRAM: States with Enacted Laws and/or Application Fees April 2009
State Alabama Arizona Colorado Delaware Idaho Illinois Maine Michigan Missouri Nebraska Nevada Ohio Oregon South Dakota Tennessee Texas Utah Vermont Washington
Laws Enacted X X X X X X X Proposed X X X X X X X
Application Fee $2,000 (Proposed) $1,000 (Proposed) $450 $1,000
$1,500 $500 (Proposed) $500 (Proposed) $3,571 $2,000 $200 $2,500
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J-1 VISA WAIVER PROCESS
Step One: Step Two:
Physician completes medical education on J-1 visa Physician submits application to US Department of State (DoS), obtains case number, and secures bona fide offer of employment from qualified Nevada health facility for minimum of 3 years Physician, employer or both apply to Nevada State Health Division to request support for waiver on physician’s behalf and to the Nevada State Board of Medical Examiners for physician license Health Division staff review and validate application, ensuring compliance with federal rules Health Division staff present findings of fact and recommendation to the Health Division Primary Care Advisory Council Health Division submits letter of support for waiver request to DoS DoS processes physician’s waiver application, reviews state’s letter of support, and makes recommendation to US Department of Homeland Security / US Citizenship and Immigration Services (USCIS) USCIS reviews recommendation, grants or denies waiver and notifies J-1 visa physician If approved, Physician receives H-1B Visa status and fulfills required minimum 3-year employment contract Physician leaves US or applies for permanent residence
Step Three:
Step Four: Step Five:
Step Six: Step Seven:
Step Eight: Step Nine:
Step Ten:
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IMPROVING ACCESS TO HEALTH CARE FOR NEVADA’S UNDERSERVED POPULATIONS: CONRAD STATE 30 / J-1 VISA WAIVER and NATIONAL INTEREST WAIVER PROGRAMS OVERVIEW Many communities throughout the U.S., both urban and rural, experience difficulties attracting physicians, especially for primary care. To address the issue, states and federal agencies have utilized foreign physicians who have just completed graduate medical education in the U.S. under J-1 visas. Ordinarily, these physicians must return home after completing their programs. However, this requirement can be waived at the request of a state or federal agency if the physician agrees to practice in an underserved area. In 1996, the U.S. General Accountability Office (GAO) reported that J-1 visa waivers had become a major source of physicians for underserved areas, a trend that continues today. CONRAD STATE 30 / J-1 VISA WAIVER The Conrad State 30 program was initiated in October 1994, and was designed to provide each of the fifty U.S. states up to 20 waivers for physicians each federal fiscal year. In 2003, the number of maximum waivers was increased to 30. Each state has been given some flexibility to implement its own guidelines, although there are some basic requirements that are common to all Conrad State 30 programs. For physicians who qualify, the Conrad State 30 program is an excellent method of obtaining a waiver. While the exact requirements vary from state to state, the following are generally required: 1. A full-time offer of employment (40 hours per week) as a primary care physician in a health professional shortage area or medically underserved area in a particular state; 2. A letter of support from the particular State Director of Health supporting the physician's Conrad State 30 request; 3. A “no-objection” letter from the foreign physician's home country, if needed; and 4. A three-year employment contract. Physicians participating in graduate medical education on J-1 visas are required to return to their home country or country of last legal residence for at least 2 years before they may apply for an immigrant visa, permanent residence, or certain nonimmigrant work visas. They may, however, obtain a waiver of this requirement from the Department of Homeland Security at the request of a state or federal agency, if they have agreed to practice in an underserved area for at least 3 years. Once the physician is granted the waiver, the employer petitions Department of Homeland Security’s U.S. Citizenship and Immigration Services (USCIS) for the physician to obtain H-1B status (a nonimmigrant classification used by foreign nationals employed temporarily in a specialty occupation).
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Obtaining a J-1 Visa Waiver at the request of a state or federal agency to practice in an underserved area involves multiple steps, which may take up to 18 months to complete. A physician must submit an application to obtain a case number from the Department of State and must secure a bona fide offer of employment from a health care facility that is located in an underserved area or, in the case of flexible waivers, from a health care facility that treats residents of an underserved area. The physician, the prospective employer, or both apply to a state or federal agency to request a waiver on the physician’s behalf. If, after reviewing the application, the state or federal agency decides to request a waiver, the state or federal agency submits a letter of request to the Department of State affirming that it is in the public interest for the physician to remain in the United States. If the Department of State decides to recommend the waiver, it forwards its recommendation to the USCIS, who is then responsible for making the final determination and notifying the physician when the waiver is granted. According to officials involved in recommending and approving waivers at the Department of State and USCIS, after a review for compliance with statutory requirements and security issues, nearly all waiver requests are recommended and granted. The physician must work at the facility specified in the waiver application for a minimum of 3 years, unless the physician obtains approval from USCIS to transfer to another facility. USCIS considers transfer requests only in extenuating circumstances, such as closure of the physician’s assigned facility. Once the physician fulfills the employment contract, the physician may apply for permanent residence, continued H-1B status, or other nonimmigrant status, if the physician wishes to remain in the United States. NATIONAL INTEREST WAIVER As part of the J-1 Visa Waiver program, the foreign physician cannot obtain permanent residence status (obtain a "green card") from the USCIS until after fulfilling his/her three-year commitment. However, the employer may start the process in stages. There are two options for the immigrant visa process: the Labor Certification or the National Interest Waiver (NIW). The National Interest Waiver (NIW) also seeks to address the problem of physician shortages in designated shortage areas by relieving the petitioner from fulfilling the U.S. Labor Certification requirements, set by the U.S. Department of Labor, which allows the physician to get permanent U.S. residence sooner. The amendment is applicable only to practicing licensed physicians (allopathic and osteopathic) and requires a letter from a state department of health with central authority for oversight of where the physician is actually practicing. The national interest waiver for physicians in underserved areas relieves the petitioner only from the labor certification process, and the individual must still meet all eligibility requirements for this immigrant classification in order to be eligible for the NIW. There is no limit on the number of NIW applicants a state may recommend during a federal fiscal year. The Labor Certification process requires the employer to initiate a recruitment period and place one journal ad. There is a risk to this process because if a qualified U.S. worker applies for the position, the labor certification application cannot be filed.
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To bypass the labor certification process entirely, the USCIS will grant a NIW on behalf of any foreign physician who has met the following criteria: 1. The foreign physician agrees to work full-time in an area designated as having a shortage of healthcare professionals; 2. A state public health department has previously determined that the foreign physician's working in such an area was in the public interest; and 3. The foreign physician works full-time in such an area for an aggregate of five years before he or she is eligible to adjust status or obtain an immigrant visa under the waiver provision. The advantage of the NIW is that no labor certification is required. The foreign physician, however, is obligated to work in the underserved area for a minimum of five years. Consequently, his/her visa would have to be extended beyond the initial three years. The NIW and the Application for Adjustment of Status to Permanent Residence may be submitted before the five-year period is completed. However, permanent residence may not be granted until the period of commitment ends in five years. NEVADA CONRAD STATE 30 / J-1 VISA WAIVER and NIW PROGRAMS The purpose of both the Nevada Conrad State 30 / J-1 Visa Waiver and National Interest Waiver programs is to improve access to health care in underserved areas of the state by increasing the number of physicians who will provide primary care to underserved populations. Currently, there are over 30 J-1 physicians serving their three year commitment in Nevada. In the summer of 2008, the Nevada Primary Care Office (PCO) began an evaluation of the Conrad State 30 / J-1 Visa Waiver (J-1) and National Interest Waiver (NIW) programs in the following areas: the provision of care to Medicaid recipients, the factors involved in the recruitment and retention of physicians in underserved areas, and the performance of the PCO. The program evaluation used three sources of data: demographic data collected routinely on the J-1/NIW physicians serving in Nevada, aggregate data from the Division of Health Care Financing and Policy regarding services provided to Medicaid clients, and the J-1/NIW survey data collected in the summer of 2008. Following are some of the areas that stood-out as successes when analyzing the performance of the PCO. Over 120 J-1 visa waiver physicians worked for Nevada sponsors in the past 8 years. 87% percent of J-1 visa waiver physicians completed their three years in Nevada. 65% of the J-1 visa waiver physicians continue working in Nevada for one year past their commitment. Over the last 7 years, J-1 visa waiver physicians have successfully increased access to care for the medically underserved populations of Nevada. An example of that success is: In North Las Vegas, the population to physician ratio is 1:5,765 without the J-1s included in the calculation; with the J-1s included in the calculation, the ratio is 1:3,459. 20
Initial data from the Division of Health Care Finance and Policy revealed that a large number of Medicaid recipients receive services from J-1 visa waiver physicians. Data collection and analysis are still in process. Table 1: Conrad State 30 / J-1 Visa Waivers in Nevada 2001-2008
2001 20/20 100% 2002 20/20 100% 2003 27/30 90% 2004 18/30 60% 2005 13/30 43% 2006 11/30 37% 2007 9/30 30% 2008 9/30 30%
The reasons are not clear regarding a 67% decline in J-1 physicians coming to Nevada since 2003. Following are some of the possible explanations: • The number of physicians who conduct their residency training on J-1 Visas dropped nationwide from 11,600 in 1996 to 6,200 in 2004. Part of this decline, according to the GAO, is that more foreign-born medical students are coming to the U.S. on the less-restrictive H-1B visa, rather than the J-1 visa. The H-1B program does not require three years of service in a HPSA area. There has been a slow increase over the last seven years in the annual number of J-1 physicians placed by government agencies in a HPSA area. According to the statistics from the Primary Care Office in Texas, 579 J-1s were placed in 2001 and 694 were placed in 2007. There was a peak year of placement, 2003, with 1033 physicians placed in that year alone. Table 2: J-1s nationwide 2001 – 2007
•
1033 854 #s of J-1 579
964
954
866 694 J-1
2001
2002
2003
2004 Year
2005
2006
2007
• •
Since the 9/11 catastrophe, the screening process for immigration has been more stringent. According to a 2006-07 investigation conducted by the Las Vegas Sun, the J-1 program in Nevada is avoided by some foreign physicians because they have heard stories of mistreatment by sponsors. In 2001 and 2002, there were six written complaints from J-1 physicians regarding Nevada sponsors not abiding by the terms of the contract. There was one complaint from a sponsor regarding the physician not abiding by the terms of the contract. Since 2002, the PCO has not received any written complaints from physicians regarding Nevada sponsors. 21
•
There has been a decline in J-1s placed in several of the other states with populations similar to Nevada. However, two states, Arkansas and Iowa, have managed to attract nearly 30 J-1 physicians per year to their state. The PCO has contacted those particular states to elicit their strategy for recruitment and retention.
Table 3: Decline of J-1s among states with similar population State Pop. 2001 2002 2003 2004 Arkansas 2,811,000 0 30 30 30 Iowa 2,982,000 20 30 30 30 Kansas 2,764,000 0 4 14 26 Mississippi 2,911,000 14 13 19 17 Nevada 2,496.000 20 30 27 18 Utah 2,550,000 18 17 4 6 •
2005 29 28 17 18 13 5
2006 14 29 17 8 11 4
2007 N/A N/A 14 9 4 1
States that have successfully placed all available J-1s each year since 2001: Arizona, California, Illinois, Kentucky, Massachusetts, Michigan, Missouri, North Carolina, Texas and Washington.
Chart 1 details the Country of Birth for Nevada J-1s placed between 2001-2008. Just over half of the waivers (55%) were granted to a combination of J-1 physicians from India, the Philippines and Pakistan. The remainder went to a combination from all over the globe. Chart 2 provides information about the counties and towns where the J-1s have been placed during that same time period. Of the 122 physicians, 105 (86%) were in the southern part of the state, and 17 (14%) were placed in the north. This is consistent with the geographic location of the state’s population and the federally designated HPSAs. Eighty-three (68%) of the J-1s were placed in the Las Vegas – North Las Vegas area.
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Chart 1: Country of Birth
Nevada: 2001 - 2008 J-1 Placements
B angladesh - 3 Canada - 1 Dominican Republic - 2 Ecuador - 1 Egypt - 3 Ghana - 4 Grenada - 1 India - 34 Iran - 1 Ireland - 1 Israel - 2 Jordan - 1 Kuwait - 1
Philippines - 19 India - 34
Lebanon - 7 Libya - 1 M alaysia - 1 M exico - 2 Nigeria - 3 P akistan - 15 P anama - 1 P eru - 3 P hilippines - 19 Romania - 3 Syria - 3 Tanzania - 1 Thailand - 1 Trinidad - 2 Turkey - 2 UK - 3
Pakistan - 15
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Chart 2: County and Towns in Nevada where J-1s were placed
Nevada: 2001 - 2008: J-1 Placements
Clark - Las Vegas - 83
Pahrump - 15
Clark - Mesquite - 2 Clark - Laughlin - 1 Clark - Moapa - 2 Lander – Battle Mtn - 2 Washoe - Reno - 6 Washoe - Gerlach - 1 Eureka - Eureka - 1 Nye - Pahrump - 15 Nye - Beatty - 2
Las Vegas – 83 (68%) North Las Vegas -
Elko - Elko - 1 Elko - Carlin - 1 Elko - Owyhee - 2 Lyon – Silver Springs - 1
Las Vegas - 83
Total 122 Total = 122
Lyon - Yerington - 1 Mineral - Hawthorne -1
RE-ENGINEERING OF NEVADA’S CONRAD STATE 30 PROGRAM The Las Vegas Sun published an extensive investigation regarding mistreatment of Conrad State 30 / J-1 Visa Waiver physicians by their sponsors/employers, beginning in late September 2007. Health Division Administration realized that an important health care access program was in jeopardy, and developed a corrective action plan. In mid-January 2008, the PCO, including the Conrad State 30 / J-1 Visa Waiver Program, was restored to the Health Division’s Bureau of Health Statistics, Planning and Emergency Response and placed under a new program manager, as the critical first step in a comprehensive corrective action plan, which included hiring a new Manager for the Primary Care Office (May 2008). Currently, there are 1.25 FTEs dedicated to the Conrad State 30 Program, and funding is provided by a combination of federal grants and a small amount (less than 5%) of General Fund. After performing a thorough program evaluation, areas requiring re-engineering were identified. There was a great need to establish a transparent process for approving J-1 Visa Waiver requests that ensured compliance with both the spirit and requirements of the Conrad State 30 Program and provided enhanced program oversight. The PCO also was not accurately tracking the J-1s from the time of application through completion of their commitment. Annual site visits were not being done. The 24
relationship with the State Board of Medical Examiners (BME) was minimal and ineffective. The Health Division determined that to ensure a transparent process, it would be best to convene a panel of external subject matter experts, who could also provide some additional program oversight. In April 2008, the Health Division Primary Care Advisory Council held its first meeting, in accordance with Nevada Open Meeting Law, and adopted its bylaws during its June 2008 meeting. The Council is comprised of representatives from a variety of organizations and stakeholders in the private and public sector that have impact on the provision of primary and specialty care within Nevada, particularly in medically underserved areas. The recommendations of the Council are advisory only, to the Administrator of the Health Division, regarding: the Conrad State 30 program; primary care provider and specialty care provider recruitment and retention efforts; health care workforce development activities, efforts and initiatives; federal Health Professional Shortage Areas and Medically Underserved Areas/Populations designations analysis, impact and stratification; and other issues impacting access to primary care and health care workforce development. The Council meets at least quarterly and the seven members are volunteers appointed by the Health Division Administrator for a term of two years. During calendar year 2008, the Council met five times and recommended approval of nine J-1 Visa Waiver applicants. Current Council members are: Gabriel Bonnet, MD – Retired Pediatrician and former Medical Director for Renown Health, Reno, NV Senator Maggie Carlton – Community Development Director, Great Basin Primary Care Association, Las Vegas, NV Charles Duarte– Administrator, Nevada Division of Health Care Financing and Policy, Carson City, NV Caroline Ford, MPH – Vice Chairperson and Assistant Dean/Director, Center for Education and Health Services Outreach, University of Nevada School of Medicine, Reno, NV Carl Heard, MD – Chief Medical Officer, Nevada Health Centers, Inc., Carson City, NV Lawrence P. Matheis – Executive Director, Nevada State Medical Association, Las Vegas, NV Amir Z. Qureshi, MD – Chairman, Infectious Diseases Specialist and former J-1 Visa Waiver physician, Las Vegas, NV
The Council’s formation has resulted in interesting outcomes. The first is an effective, collaborative relationship between the PCO and State Board of Medical Examiners. J-1 Visa Waiver applicant bottlenecks are being addressed and licenses are being issued in a timely manner. BME staff regularly attends Council meetings, and PCO staff represent the Health Division at the quarterly BME meetings. The two agencies are working together on how to handle mistreatment complaints and prevent further abuse of the J-1s. Also, the two are working together to gather data, for better tracking of the all physicians, in order to meet various other related statutory and federal requirements. The PCO has drafted program policies and procedures, which have been vetted 25
through an open meeting process, to ensure that the program is administered in a manner that is consistent and compliant with federal requirements. These policies and procedures are expected to be implemented by the end of state fiscal year 2009. Because the Council has found some of the program’s federal requirements lack clarity, Senator Carlton is seeking legislation during the 2009 session to remedy this situation; as several other states have this type of legislation, including Oregon, Utah and Washington. The PCO has developed and implemented a tracking system that allows it to monitor a J-1 physician from the time a waiver application is received through the completion of their waiver commitment. Both annual and ad hoc site visits are now being conducted and these have enhanced both program compliance and communication with the J-1s and their employers. The PCO has found that neither the J-1s nor the employers fully understood their rights and responsibilities, and an education/orientation program is in development. It is also expected to become an effective recruitment tool. INTERIM LEGISLATIVE REPORTS During the 2007-2008 interim and a result of the Las Vegas Sun investigative reports, two program reports were requested by the Legislative Committee on Health Care (October 2007 and February 2008) and one by the Legislative Committee on Health Care Subcommittee to Review the Laws and Regulations Governing Providers of Health Care, the Use of Lasers and Intense Pulsed Light Therapy, and the Use of Injections of Cosmetic Substances (May 2008). While the members of both Committees were pleased with the program changes made, they will continue to monitor the situation until the problems have been resolved to their satisfaction. SUMMARY Nevada’s Conrad State 30 / J-1 Visa Program is critical for improving access to health care for the those residents living in underserved areas. While sustainable, effective measures have been put into place to resolve key problems, the program has a long way to go toward rebuilding its credibility and reputation. The Health Division is committed to strengthening this program, as a means to better meeting health care needs in the Silver State.
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PRIMARY CARE ACCESS: UNDERSERVED AREAS
Nevada’s Primary Care Office is responsible identifying and obtaining federal designation for a Health Professional Shortage Area (HPSA), Medically Underserved Area (MUA), and Medically Underserved Population (MUP) within the Silver State.
HPSA designations and renewals are awarded by the U.S. Department of Health and Human Services Health Resources and Services Administrations (HRSA). Health Professional Shortage Area (HPSA): The designation is based on a minimum practitioner to population ratio, and is awarded for shortages of primary care, dental or mental health providers The designation can be given to an entire county or to certain areas within a county. HPSA designations are used by over 30 federal programs for funding determinations, including Medicare and Medicaid.
Primary Care Dental Mental Health
HPSA Ratio (minimum) 1 : 3,500 1: 5,000 1 : 30,000
Ideal Ratio 1 : 2,000 1 : 3,000 1 : 10,000
Medically Underserved Area (MUA): The designation may be given to a whole county or to a group of contiguous counties, a group of county or civil divisions, or a group of urban census tracts in which residents have a shortage of personal health services. Medically Underserved Population (MUP): The designation may include groups of persons who face economic, cultural or linguistic barriers to health care.
Underserved Type HPSA – Primary Care HPSA – Dental HPSA – Mental Health MUA MUP
# Nevada designations 51 17 18 8 5
Total # US Designations 6,033 4,048 3,059 Not Available Not Available
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Nevada Health Care Shortage / Underserved Areas
County/Area Carson City Churchill County Clark County Primary Care FQHC only Tribal only FQHCs and Tribal only X X X X X X X Tribal only Tribal only Jawbridge, Mountain City and Owyhee only Jackpot, West Wendover and Wells only X X X X X X X X X X FQHC and Tribal only X X X X X X X HPSA Dental FQHC only All except North Las Vegas Mental Health FQHC only X X MUA MUP Eastern only
Clark – Cambridge Clark – Indian Springs Clark – Las Vegas
Metro
Clark – Laughlin Clark – North Las
Vegas
Clark – Overton Clark – Sunrise Douglas County Elko County Elko – Northern
X
X
City of Elko only
Elko – Eastern
Esmeralda County Eureka County Humboldt County Lander County Lincoln County Lyon County Mineral County Nye County Pershing County Storey County Washoe County Washoe – Reno/Sparks Washoe – Gerlach White Pine County
X X X X X X X X X
X X X X X X X X X X X
Jackpot and West Wendover only X X X X X
X
X
FQHC = Federally Qualified Health Center
28
Federal Programs Using HPSA Designations
National Health Service Corps (NHSC)—Section 333 of Public Health Service Act. Provides for the assignment of federally-employed and/or service obligated physicians and dentists to Health Professional Shortage Areas (HPSAs) NHSC –Scholarship Program (Section 338A) provides scholarships for training of health professionals to serve in HPSAs NHSC Loan Repayment Program (Section 338 B) provides load repayment to health professional who serve in HPSAs Rural Health Clinics Act (PL 95-210) provides Medicare and Medicaid reimbursement for services provided by PAs and Nurse Practitioners in clinics in rural HPSAs CMS (Center for Medicare and Medicaid Services) Medicare Incentive Payment for Physician’s Services provided in HPSAs (PL 100-203, Section 4043 as amended) gives 10% bonus payment for Medicare-reimbursable physician services within geographic HPSAs. (Does not apply to population group HPSAs) CMS (Center for Medicare and Medicaid Services) Higher “Customary Charges” for new physicians in HPSAs (PL 100-203 Section 4047) exempts new physicians opening practices in non-metropolitan geographic HPSAs from new Medicare limitations on “customary charges” AHECs (Section 781 (a)(1) gives special consideration to centers that serve HPSAs with higher percentage of underserved minorities Federal Employees Health Benefits Programs—provides reimbursement for non physician services in states with high percentages of their population residing in HPSAs Conrad State30 / J-1 Visa Waiver program for foreign born physicians Nevada State Immunization Program Tribal Health Centers and outpatient health programs (Indian Self Determination Act or Indian Health Care Improvement Act) Eligibility for various Title VII and VIII Grants • Graduate and Residency trainings in Family Medicine • Faculty Development in Family Medicine, General Internal Medicine & General Practice • Faculty training project in Geriatric Medicine and Dentistry • Residency Training & Advanced Education in General Practice of Dentistry • Preventative Medicine & Dental Public Health • Physician Assistant Training Program • Podiatric Primary Care Residency Program • Allied Health Project Grants • Health Education and Training Programs • Interdisciplinary training for Health Care in Rural Areas • Health Administration Traineeships and Special Projects • Special Project grants to Schools of Public Health • Nurse Practitioner and Nurse Midwifery Education programs • Programs of Excellence in Health Professions Education for Minorities • Cooperative Agreements to Improve the Health Status of Minority Population • Emergency Medical Services for Children • Professional Nurse and Nurse Anesthetist Traineeships • Nurse Training Improvement: Special Projects SAMHSA (Substance Abuse and Mental Health Services Administration—grants for Mental Health Clinics and AIDS SERVICE-Related Training FQHC (Federally Qualified Health Centers) funded by PHS Act Section 330 – automatic HPSA designation FQHCLA (Federally Qualified Health Center Look Alike) certified by CMS as meeting the definition of Health Center in Section 330 but do not receive grant funding
29
F A C T SHEET
Federally Qualified Health Center
effective October 1, 1991 when Section 1861(aa) of the Social Security Act (the Act) was amended by Section 4161 of the Omnibus Budget Reconciliation Act of 1990. FQHCs are “safety net” providers such as community health centers, public housing centers, outpatient health programs funded by the Indian Health Service, and programs serving migrants and the homeless. The main purpose of the FQHC Program is to enhance the provision of primary care services in underserved urban and rural communities.
Federally Qualified Health Center Designation
An entity may qualify as an FQHC if it:
■ Is receiving a grant under Section 330 of the
T
HE
FEDERALLY QUALIFIED HEALTH CENTER (FQHC) benefit under Medicare was added
Public Health Service (PHS) Act;
■ Is receiving funding from such grant under a
as an urban Indian organization receiving funds under Title V of the Indian Health Care Improvement Act as of October 1, 1991.
contract with the recipient of a grant and meets the requirements to receive a grant under Section 330 of the PHS Act;
■ Is not receiving a grant under Section 330 of
Covered Federally Qualified Health Center Services
Payments are made directly to the FQHC for covered services furnished to Medicare beneficiaries. Services are covered when furnished to a beneficiary at the FQHC, the beneficiary’s place of residence, or elsewhere (e.g., at the scene of an accident). A FQHC generally furnishes the following services:
■ Physician services; ■ Services and supplies incident to the services
the PHS Act but determined by the Secretary of the Department of Health and Human Services (HHS) to meet the requirements for receiving such a grant (i.e., qualifies as a FQHC look-alike) based on the recommendation of the Health Resources and Services Administration;
■ Was treated by the Secretary of the Depart-
of physicians;
■ Nurse practitioner (NP), physician assistant
ment of HHS for purposes of Medicare Part B as a comprehensive Federally funded health center as of January 1, 1990; or
■ Is operating as an outpatient health program
(PA), certified nurse midwife (CNM), clinical psychologist (CP), and clinical social worker (CSW) services;
■ Services and supplies incident to the services
or facility of a tribe or tribal organization under the Indian Self-Determination Act or
of NPs, PAs, CNMs, CPs, and CSWs;
F EDER A L LY QU AL IF IED HEAL T H C ENT ER F AC T SHEET
1
■ Visiting nurse services to the homebound in
■ Clinical breast examination; ■ Referral for mammography; and ■ Thyroid function test.
an area where the Centers for Medicare & Medicaid Services (CMS) has determined that there is a shortage of Home Health Agencies;
■ Otherwise covered drugs that are furnished
by, and incident to, services of physicians and nonphysician practitioners of the FQHC; and
■ Outpatient diabetes self-management training
Federally Qualified Health Center Preventive Primary Services that are NOT Covered
FQHC preventive primary services that are NOT covered include:
■ Group or mass information programs, health
and medical nutrition therapy for beneficiaries with diabetes or renal disease (effective for services furnished on or after January 1, 2006). FQHCs also furnish preventive primary health services when furnished by or under the direct supervision of a physician, NP, PA, CNM, CP, or CSW. The following preventive primary health services are covered when furnished by FQHCs to Medicare beneficiaries:
■ Medical social services; ■ Nutritional assessment and referral; ■ Preventive health education; ■ Children’s eye and ear examinations; ■ Well child care including periodic screening; ■ Immunizations including tetanus-diphtheria
education classes, or group education activities including media productions and publications; and
■ Eyeglasses, hearing aids, and preventive
dental services. Items or services that are covered under Part B, but are NOT FQHC services include:
■ Certain laboratory services; ■ Durable medical equipment, whether rented
or sold, including crutches, hospital beds, and wheelchairs used in the beneficiary’s place of residence;
■ Ambulance services; ■ The technical component of diagnostic tests
booster and influenza vaccine;
■ Voluntary family planning services; ■ Taking patient history; ■ Blood pressure measurement; ■ Weight measurement; ■ Physical examination targeted to risk; ■ Visual acuity screening; ■ Hearing screening; ■ Cholesterol screening; ■ Stool testing for occult blood; ■ Tuberculosis testing for high risk beneficiaries; ■ Dipstick urinalysis; and ■ Risk assessment and initial counseling
such as x-rays and electrocardiograms;
■ The technical component of the following
preventive services: Screening pap smears; Prostate cancer screening; Colorectal cancer screening tests; Screening mammography; and Bone mass measurements;
regarding risks. For women only:
■ Prenatal and post-partum care; ■ Prenatal services;
F EDER A L LY Q U AL IFI ED H EAL T H C EN T ER F AC T SHEET
2
■ Prosthetic devices that replace all or part of an
area for FQHC payment limit purposes. Freestanding FQHCs must complete Form CMS-222-92, Independent Rural Health Clinic and Freestanding Federally Qualified Health Center Cost Report, in order to identify all incurred costs applicable to furnishing covered FQHC services. Form CMS-222-92 can be found in the Provider Reimbursement Manual—Part 2 (Pub. 15-2), Chapter 29, located at http://www.cms.hhs.gov/ Manuals/PBM/list.asp on the CMS website. Provider-based FQHCs must complete the appropriate worksheet designated for FQHC services within the parent provider’s cost report. For example, FQHCs based in a hospital complete Worksheet M of Form CMS-2552-96, Hospital and Hospital Complex Cost Report. At the beginning of the FQHC’s fiscal year, the Fiscal Intermediary or A/B Medicare Administrative Contractor calculates an interim all-inclusive visit rate based on either estimated allowable costs and visits from the FQHC (if it is new to the FQHC Program) or on actual costs and visits from the previous cost reporting period (for existing FQHCs). The FQHC’s interim all-inclusive visit rate is reconciled to actual reasonable costs at the end of the cost reporting period. Form CMS-2552-96 can be found in the Provider Reimbursement Manual—Part 2 (Pub. 15-2), Chapter 36, located at http://www.cms.hhs.gov/ Manuals/PBM/list.asp on the CMS website. Influenza and Pneumococcal Vaccine Administration and Payment The cost of the influenza and pneumococcal vaccines and related administration are separately reimbursed at annual cost settlement. There is a separate worksheet on the cost report to report the cost of these vaccines and related administration. These costs should not be reported on a FQHC claim when billing for FQHC services. The beneficiary pays no Part B deductible or coinsurance for these services. When a FQHC practitioner (e.g., a physician, NP, PA, or CNM) sees a beneficiary for the sole purpose of administering these vaccinations, the FQHC may not bill for a visit; however, the associated costs are included on the annual cost report and reimbursed at cost settlement.
internal body organ including colostomy bags, supplies directly related to colostomy care, and the replacement of such devices; and
■ Leg, arm, back, and neck braces and artificial
legs, arms, and eyes including replacements (if required because of a change in the beneficiary’s physical condition).
Federally Qualified Health Center Payments
Generally, Medicare pays FQHCs (which are considered suppliers of Medicare services) an all-inclusive per visit payment amount based on reasonable costs as reported on its annual cost report. The beneficiary pays no Part B deductible for FQHC services but is responsible for paying the coinsurance with the exception of FQHCsupplied influenza and pneumococcal vaccines, which are paid at 100 percent. Generally, the coinsurance for FQHC services is 20 percent of the clinic’s reasonable and customary charge except for psychological or psychiatric therapeutic services (generally furnished by CPs and CSWs), which are subject to the 62.5 percent outpatient mental health treatment limitation. This limit does not apply to diagnostic services. The application of the outpatient mental health treatment limitation increases the beneficiary’s copayment to 50 percent of the clinics’s reasonable and customary charge. The FQHC all-inclusive visit rate is calculated, in general, by dividing the FQHC’s total allowable cost by the total number of visits for all FQHC patients. The FQHC payment methodology includes two national per-visit upper payment limits—one for urban FQHCs and one for rural FQHCs. The two national FQHC per-visit upper payment limits are increased annually by the Medicare Economic Index applicable to primary care physician services. A FQHC is designated as an urban or rural entity based on definitions in Section 1886(d)(2)(D) of the Act. If a FQHC is not located within a Metropolitan Statistical Area (now generally known as a Core Based Statistical Area) or New England County Metropolitan Area, it is considered rural and the rural limit applies. Rural FQHCs cannot be reclassified into an urban
F EDER A L LY Q U AL IFI ED H EAL T H C EN T ER F AC T SHEET
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Hepatitis B Vaccine Administration and Payment The cost of the Hepatitis B vaccine and related administration are covered under the FQHC’s allinclusive rate. If other services that constitute a qualifying FQHC visit are furnished at the same time as the Hepatitis B vaccination, the charges for the vaccine and related administration can be included in the charges for the visit when billing and in calculating the coinsurance. When a FQHC practitioner (e.g., a physician, NP, PA, or CNM) sees a beneficiary for the sole purpose of administering a Hepatitis B vaccination, the FQHC may not bill for a visit; however, the associated costs are included on the annual cost report. Charges for the Hepatitis B vaccine may be included on a claim for the beneficiary’s subsequent FQHC visit and used in calculating the coinsurance.
Medicare Prescription Drug, Improvement, and Modernization Act of 2003 Provisions that Impact Federally Qualified Health Centers
Section 410 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 states that professional services furnished on or after January 1, 2005 by physicians, NPs, PAs, and CPs who are affiliated with FQHCs are excluded from the Skilled Nursing Facility Prospective Payment System, in the same manner as such services would be excluded if furnished by individuals not affiliated with FQHCs. To find additional information about FQHCs, see Chapter 9 of the Medicare Claims Processing Manual (Pub. 100-4) and Chapter 13 of the Medicare Benefit Policy Manual (Pub. 100-2) at http://www.cms.hhs.gov/Manuals and the Federally Qualified Health Centers Center at http://www. cms.hhs.gov/center/fqhc.asp on the CMS website.
HELPFUL RURAL HEALTH WEBSITES CENTERS FOR MEDICARE & MEDICAID SERVICES’ WEBSITES CMS Manuals http://www.cms.hhs.gov/Manuals Critical Access Hospital Center http://www.cms.hhs.gov/center/cah.asp Federally Qualified Health Centers Center http://www.cms.hhs.gov/center/fqhc.asp Hospital Center http://www.cms.hhs.gov/center/hospital.asp HPSA/PSA (Physician Bonuses) http://www.cms.hhs.gov/ hpsapsaphysicianbonuses/01_overview.asp Medicare Learning Network http://www.cms.hhs.gov/MLNGenInfo MLN Matters Articles http://www.cms.hhs.gov/MLNMattersArticles Rural Health Center http://www.cms.hhs.gov/center/rural.asp Telehealth http://www.cms.hhs.gov/Telehealth
This fact sheet was prepared as a service to the public and is not intended to grant rights or impose obligations. This fact sheet may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents. The Medicare Learning Network (MLN) is the brand name for official CMS educational products and information for Medicare fee-for-service providers. For additional information visit the Medicare Learning Network’s web page at http://www.cms.hhs. gov/MLNGenInfo/ on the CMS website. Medicare Contracting Reform (MCR) Update In Section 911 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) Congress mandated that the Secretary of the Department of Health and Human Services replace the current contracting authority under Title XVIII of the Social Security Act with the new Medicare Administrative Contractor (MAC) authority. This mandate is referred to as Medicare Contracting Reform. Medicare Contracting Reform is intended to improve Medicare’s administrative services to beneficiaries and health care providers. All Medicare work performed by Fiscal Intermediaries and Carriers will be replaced by the new A/B MACs by 2011. Providers may access the most current MCR information to determine the impact of these changes and to view the list of current MACs for each jurisdiction at http://www.cms.hhs.gov/MedicareContractingReform on the CMS website. April 2008 ICN: 006397
OTHER ORGANIZATIONS’ WEBSITES American Hospital Association Section for Small or Rural Hospitals http://www.aha.org/aha/key_issues/rural/index.html Health Resources and Services Administration http://www.hrsa.gov National Association of Community Health Centers http://www.nachc.org National Association of Rural Health Clinics http://www.narhc.org National Rural Health Association http://www.nrharural.org Rural Assistance Center http://www.raconline.org U.S. Census Bureau http://www.Census.gov
F EDER A L LY Q U AL IFI ED H EAL T H C EN T ER F AC T SHEET
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k aiser commission
on
medicaid and the unin sured
March 2009
Community Health Centers
Community health centers represent a key component of the health care system, providing comprehensive primary care to 16.1 million patients in 2007. Nearly all health center patients have low family incomes and live in medically underserved communities, and many have complex medical conditions. Health centers serve as an important source of care for these patients, but their role is even more critical during an economic recession when families are more vulnerable to economic loss and unmet health care needs.
KEY CHARACTERISTICS OF HEALTH CENTERS
Figure 1
Health Center Patients by Income, 2007
>200% FPL 9%
(1.2 million)
101-200% FPL 21%
(3.2 million)
Health centers operate 7,200 sites throughout the United States, particularly in economically depressed inner-city and rural communities. Over the past ten years, as the number of health center sites has grown, the number of patients served at health centers has nearly doubled, from 8.3 million to 16.1 million in 2007. Health centers include two types of clinics: those that receive federal funding under Section 330 of the Public Health Service Act, as well as clinics that meet all requirements applicable to federally funded health centers are supported through state and local grants. Both types of community health centers are classified as “federally qualified health centers” (FQHCs), a designation that entitles them to special payment rates under Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP). Federal law requires that health centers must: Be located in, or targeted to serve, populations and communities that are medically underserved or experience a shortage of primary care professionals; Provide a comprehensive array of specified primary health care services and fully participate in government insurance programs; Establish sliding fee scales based on patients’ ability to pay for care; and Have community boards, a majority of whose members are health center patients.
PATIENTS SERVED BY HEALTH CENTERS
<100% FPL 70%
(10.6 million)
Total = 16.1 million
SOURCE: GWU Department of Health Policy analysis of 2007 UDS data, HRSA.
In part because of their low-income, three-quarters of health center patients are uninsured or covered by Medicaid. In 2007, nearly 40 percent of all health center patients were uninsured and another 35 percent were covered by Medicaid. While 16 percent of health center patients have some level of private health insurance, research suggests that many of these patients have policies that have high deductibles and cost-sharing and limited coverage, leaving them un- or underinsured for key services (Figure 2).
Figure 2
Health Center Patients by Insurance Status, 2007
Private
16% (2.5 million)
Uninsured
39% (6.2 million)
Medicaid Other Public
2% (0.4 million) 35% (5.7 million)
Health center patients are predominantly low-income and racially and ethnically diverse. In 2007, 70 percent of all patients had family incomes at or below 100 percent of the federal poverty level ($21,203 for a family of four) and more than 90 percent of patients had family incomes at or below twice the poverty level (Figure 1). In 2007, minority patients comprised half of all health center patients, and one-third of all health center patients were of Hispanic/Latino ethnicity. Health centers serve one in four low-income minority residents. They also provide services to rural and homeless populations, and to migrant workers, all of whom would otherwise not likely have access to care.
Medicare
8% (1.2 million)
Total = 16.1 million
SOURCE: GW Department of Policy analysis of 2007 UDS data, HRSA.
SERVICES, ACCESS AND QUALITY
Health centers provide primary and preventive care services to a complex population. Health centers also increasingly provide, or arrange for, an array of services including dental and mental health care. Health centers play an especially important role for low-income women of childbearing age,
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infants, and children. In 2007, approximately one in eight low-income babies was born to health center patients. Health centers serve an important role in improving access to care and reducing disparities. Research shows that on measures for which data have been collected, the quality of care provided to health center patients is comparable to the care received in other health care settings and to some national benchmarks. Research also shows that Medicaid and uninsured patients served in health centers are more likely to receive preventive services such as counseling on diet, smoking cessation, and alcohol consumption, than in other practice settings. While health centers are able to provide comprehensive primary care, access to specialty care for patients with complex medical problems is limited due to a lack of available providers, particularly for uninsured and Medicaid patients (Figure 3). It is especially difficult to refer these patients for mental health and substance abuse services.
Figure 3
Figure 4
Health Center Patients and Revenues by Payer Source, 1985 to 2007
Medicaid
9% 14% 29% 5% 49% 51% 39% 21%
Uninsured
Private
2%
Medicare
8% 16%
Other
29% 6% 7%
28% 15%
35%
37%
Patients
Revenues
Patients
Revenues
1985
2007
NOTE: 1985 Other revenue includes Private Insurance revenue SOURCE: Center for Health Services Research and Policy analysis of 2007 UDS, HRSA; 1985 estimates by NACHC using BCRR data (no private revenue data provided for 1985).
CHALLENGES AND OPPORTUNITIES
The current economic recession has led to economic instability and unmet health needs for many families. While health centers are uniquely positioned to provide care to these families, meeting the increased demand for services will be a challenge. Federal support has been especially important in health centers’ ability to meet the ongoing needs of their patients. The Health Care Safety Net Act of 2008 reauthorizes the health centers program for four years and anticipates program growth of 50 percent over this time period. Other recent legislation provides support in the areas of capital investment, workforce, modernization, and operations, and extends to CHIP the same payment methodology for health centers that is used in Medicaid. While these legislative actions should strengthen health centers, other challenges remain. Across the country, the primary care workforce has been unable to keep up with growing demand. Health centers, especially those in rural locations, will continue to struggle to attract and retain clinical staff. Barriers to referring Medicaid and uninsured patients for specialty care will also be a major obstacle to obtaining needed services. Additionally, health centers may struggle to afford health information technology that care providers across the country are looking to adopt. Despite these challenges, health centers remain an essential part of our health care system. As the country prepares for a major debate over how to reform the health care system and provide coverage to the 45 million uninsured, understanding the components of the current system will be important. The health reform debate will likely focus on health coverage, but also on access, quality, and efficiency. In light of their critical position in the health care system, health centers appear to lie at the nexus of this broadened concept of health reform.
This publication (#7877) is available on the Kaiser Family Foundation’s website at www.kff.org.
Patient Visits Experiencing Referral Difficulties, by Coverage Source: Health Centers and Physician Practices, 2006
Physician Office
72% 54% 39% 40%
Health Center
14%
10%
12% 14%
Uninsured
Medicaid
Medicare
Private
SOURCE: CDC/NCHS, 2006 National Ambulatory Medical Care Survey by Esther Hing and David A. Woodwell, Differences in physician visits at community health centers and physician offices: United States, 2008.
FINANCING
Health Centers depend on a combination of Medicaid payments, grant revenues, and other sources of funding to support their operations. Over the years, the funding mix that health centers receive has significantly changed (Figure 4). As grants have declined, health center expansions have been fueled by Medicaid growth resulting from eligibility expansions, coverage reforms, and changed payment rules. In 1985, Medicaid patients reflected 28 percent of all patients but only 15 percent of revenues. By 2007, Medicaid patients and revenues were aligned while grants for the care of the uninsured decreased from 51 percent to 21 percent. At the same time, private insurance represented 16 percent of patients but only 6 percent of operating revenues.
F A C T SHEET
Rural Health Clinic
RURAL HEALTH CLINIC (RHC) PROGRAM was established in 1977 to address an inadequate supply of physicians who serve Medicare and Medicaid beneficiaries in rural areas. The program provides qualifying Clinics located in rural and medically underserved communities with payment on a cost-related basis for outpatient physician and certain nonphysician services. For RHC purposes, any area that is not defined by the U.S. Census Bureau as urbanized is considered non-urbanized. RHCs are located in areas that are designated or certified by the Secretary of the Department of Health and Human Services as Health Professional Shortage Areas (HPSA) or Medically Underserved Areas (MUA). A Clinic cannot be Medicare approved concurrently as a RHC and a Federally Qualified Health Center.
T
HE
Rural Health Clinic Services RHCs furnish the following: Physicians’ services; Services and supplies incident to the services of physicians; Services of registered dietitians or nutritional professionals for diabetes training services and medical nutrition therapy (the costs of such services are covered but not as a billable RHC visit); Otherwise covered drugs that are furnished by, and incident to, services of physicians and nonphysician practitioners of the RHC; Services of nurse practitioners (NP), physician assistants (PA), certified nurse midwives (CNM), clinical psychologists (CP), and clinical social workers (CSW); Services and supplies incident to the services of NPs, PAs, CNMs, CPs, and CSWs; and Visiting nurse services to the homebound in an area where the Centers for Medicare
& Medicaid Services (CMS) has certified a shortage of home health agencies exists. Rural Health Clinic Designation To qualify as a Rural Health Clinic, a Clinic must be located in: A non-urbanized area, as defined by the U.S. Census Bureau, and in an area with one of the following current designations:
• MUA; • Geographic or population-based HPSA; or • Governor-designated and Secretarycertified shortage area.
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A shortage or underserved designation must have been designated or redesignated in the current year or in one of the previous three years. A RHC must also: Employ a midlevel practitioner who is available to furnish services at least 50 percent of the time the Clinic is furnishing services; Furnish routine diagnostic and laboratory services; Establish arrangements with providers and suppliers to furnish medically necessary services not available at the Clinic; and Furnish first response emergency care. Rural Health Clinic Payments Payment for RHC services furnished to Medicare patients is made on the basis of an all-inclusive rate per covered visit with the exception of psychological or psychiatric therapeutic services. All therapeutic services furnished by CSWs and CPs are subject to the outpatient mental health treatment limitation. This limit does not apply to diagnostic services. A visit is defined as a face-toface encounter between the patient and one of the following practitioners, during which a RHC service is furnished: A physician; NP; PA; CNM; CP; CSW; or Visiting nurse (in very limited cases). The cost of the influenza and pneumococcal vaccines and related administration are separately reimbursed at annual cost settlement. There is a separate worksheet on the Independent Rural Health Clinic and Freestanding Federally Qualified Health Center Cost Report to report the cost of these vaccines and related administration. These costs should never be reported on the claim when billing for RHC services. There is no coinsurance or deductible for these services; therefore, when these vaccines are administered, the charges for the vaccines and related administration are never included with the visit charges when calculating coinsurance or deductible for the visit. When a RHC physician, PA, NP or , CNM sees a beneficiary for the sole purpose of administering these vaccinations, the RHC may not bill for a visit; however, the associated costs should still be included on the annual cost report. The cost of the Hepatitis B vaccine and related administration are covered under the RCH’s allinclusive rate. If other services that constitute a qualifying RHC visit are furnished at the same time as the Hepatitis B vaccination, the charges for the vaccine and related administration can be included in the charges for the visit when billing and in calculating the coinsurance and /or deductible. When a physician, NP PA, or CNM , sees a beneficiary for the sole purpose of administering a Hepatitis B vaccination, he or she may not bill for a visit; however, the associated costs should still be included on the annual cost report. Charges for the Hepatitis B vaccine may be included on a claim for the beneficiary’s subsequent RHC visit and in calculating coinsurance and/or deductible.
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Encounters at a single location on the same day with more than one health professional and multiple encounters with the same health professional constitute a single visit, except when one of the following conditions exist: The patient suffers an illness or injury requiring additional diagnosis or treatment subsequent to the first encounter; or The patient has a medical visit AND a clinical psychologist or clinical social worker visit. Payment is made directly to RHCs for covered services furnished to a patient at the Clinic, the patient’s place of residence, or elsewhere (e.g., the scene of an accident). Laboratory tests are paid separately. The Medicare Part B deductible applies to RHC services and is based on billed charges. Noncovered expenses do not count toward the deductible. After the deductible has been satisfied, RHCs will be paid 80 percent of the allinclusive interim encounter payment rate for each RHC visit with the exception of all psychological or psychiatric therapeutic services furnished by CSWs and CPs. Independent RHCs must complete Form CMS-222-92, Independent Rural Health Clinic and Freestanding Federally Qualified Health Center Cost Report, in order to identify all incurred costs applicable to furnishing covered Clinic services including RHC direct costs and any shared costs applicable to the RHC. An independent RHC is limited to the yearly national RHC per-visit payment ceiling for its encounter rate. Form CMS-222-92 can be found at www.cms.hhs.gov/ CMSForms/CMSForms/list.asp on the CMS website. Provider-based RHCs must complete Worksheet M of Form CMS-2552-96, Hospital Cost Report, in order to identify all incurred costs applicable
to furnishing covered Clinic services and the RHC’s appropriate share of the parent provider’s overhead costs. A RHC that is provider-based to a hospital with less than 50 beds is not subject to the national per-visit payment ceiling and has an encounter rate that is based on its full reasonable cost. If a RHC is in its initial reporting period, the all-inclusive visit rate is determined on the basis of a budget the RHC submits. The budget estimates the allowable cost that will be incurred by the RHC during the reporting period and the number of visits for RHC services expected during the reporting period. Form CMS-2552-96 can be found in the Provider Reimbursement Manual–Part 2 (Pub. 15-2), Chapter 36, which can be found at www.cms.hhs.gov/Manuals/PBM/ list.asp on the CMS website. To determine the payment rate for new RHCs and for those that have submitted cost reports, the Fiscal Intermediary (FI) applies screening guidelines and the maximum payment per-visit limitation as described below. For subsequent reporting periods, the all-inclusive visit rate is determined, at the discretion of the FI, on the basis of a budget or the prior year’s actual costs and visits with adjustments to reflect anticipated changes in expenses or utilization. In general, the payment rate is calculated by dividing the total allowable cost by the number of total visits for RHC services. At the end of the annual cost reporting period, RHCs submit a report to the FI that includes actual allowable costs and actual visits for RHC services for the reporting period and any other information that may be required. After reviewing the report, the FI divides actual allowable costs by the number of actual visits to determine a final rate for the period. Both the final rate and the interim rate are subject to screening guidelines for evaluating the reasonableness of the Clinic’s productivity, payment limit, and mental health treatment limit.
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Annual Reconciliation At the end of the annual cost reporting period, the FI determines the total payment due and the amount necessary to reconcile payments made during the period with the total payment due. Medicare Prescription Drug, Improvement, and Modernization Act of 2003 Section 410 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 states that professional services furnished on or after January 1, 2005, by physicians, PAs, NPs, and CPs who are affiliated with RHCs are excluded from the Skilled Nursing Facility
Prospective Payment System, in the same manner as such services would be excluded if furnished by individuals not affiliated with RHCs.
HELPFUL RURAL HEALTH WEBSITES
CENTERS FOR MEDICARE & MEDICAID SERVICES’ WEBSITES CMS Forms www.cms.hhs.gov/CMSForms/CMSForms/list.asp CMS Mailing Lists www.cms.hhs.gov/apps/mailinglists Critical Access Hospital Provider Center www.cms.hhs.gov/center/cah.asp Federally Qualified Health Centers Provider Center www.cms.hhs.gov/center/fqhc.asp Hospital Provider Center www.cms.hhs.gov/center/hospital.asp HPSA/PSA (Physician Bonuses) www.cms.hhs.gov/HPSAPSAPhysicianBonuses Internet-Only Manuals www.cms.hhs.gov/Manuals/IOM/list.asp Paper-Based Manuals www.cms.hhs.gov/Manuals/PBM/list.asp Medicare Learning Network www.cms.hhs.gov/MLNGenInfo Medicare Modernization Update www.cms.hhs.gov/MMAUpdate/MMU/list.asp MLN Matters Articles www.cms.hhs.gov/MLNMattersArticles Physician’s Resource Partner Center www.cms.hhs.gov/center/physician.asp Regulations & Guidance www.cms.hhs.gov/home/regsguidance.asp OTHER ORGANIZATIONS’ WEBSITES American Hospital Association Section for Small or Rural Hospitals www.aha.org/aha/key_issues/rural/index.html Government Printing Office—Code of Federal Regulations www.gpoaccess.gov/cfr/index.html Health Resources and Services Administration www.hrsa.gov National Association of Community Health Centers www.nachc.org National Association of Rural Health Clinics www.narhc.org National Rural Health Association www.nrharural.org Rural Assistance Center www.raconline.org U.S. Census Bureau www.census.gov Rural Health Center www.cms.hhs.gov/center/rural.asp Telehealth www.cms.hhs.gov/Telehealth
This fact sheet was p epared as a service to the public and is not intended to grant rights or impose obligations. This fact sheet may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents. The Medicare Learning Network (MLN) is the brand name for official CMS educational products and information for Medicare fee-for-service providers. For additional information visit the Medicare Learning Network’s web page at www.cms.hhs.gov/MLNGenInfo/ on the CMS website. Medicare Contracting Reform (MCR) Update Section 911 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) Congress mandated that the Secretary of the Department of Health and Human Services replace the current contracting authority under Title XVIII of the Social Security Act with the new Medicare Administrative Contractor (MAC) authority. This mandate is referred to as Medica e Contracting Reform. Medicare Contracting Reform is intended to improve Medicare’s administrative services to beneficiaries and health care providers. Currently, there are three Durable Medical Equipment (DME) MACs that handle the processing of DME claims and one A/B MAC (Jurisdiction 3) to handle the processing of both Part A and Part B claims for those beneficiaries located within the states included in Jurisdiction 3. All Medicare work performed by Fiscal Intermediaries and Carriers will be replaced by the new A/B MACs by 2011. Providers may access the most cur ent MCR information to determine the impact of these changes at www.cms.hhs.gov/MedicareContractingReform on the CMS website. June 2007 ICN: 006398
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