Children's Special Health Services
Sub-Committee of the Family Health Advisory Council - Current Minutes
Chair: CSHS Advisory Committee Meeting
February 3, 2006
1310 East Lockey Avenue
Room 105
10:00 am
Participating: MaryLynn Donnelly, RN; Sylvia Danforth, DEAP Director; Corliss Scott, Outreach Coordinator; Mary Anne Guggenheim, MD; Lori Byron, MD; John Johnson, MD; Laura Nicholson, MD; BJ Archambault, RN; Gerald Eichner, MD; Peggy Schlesinger, MD; Ellen Carey, RN Western Regional Clinic; Cyndi Leaphart, RN Eastern Regional Clinic; Jo Ann Dotson, Bureau Chief; Ellen Carey, RN; Mo Leo, Parent; and Susan Gardipee, Family Member.
Organization Updates:
Division Changes (Jo Ann Dotson) The Children's Special Health Services (CSHS) section is moving back into the Family and Community Health Bureau in the Division of Public Health and Safety from the Health Resources Division. There has been great progress over the past few years to assure more children with special health care needs are now covered under CHIP and Medicaid. As a result of these CHIP/Medicaid eligibility changes, CSHS has been able to shift a substantial portion of its direct pay services. The current CSHS Section's focus has turn toward developing a system of care for children with special health care needs one of the national MCH Performance Measures. Direct payment for services has been gradually reduced over the years. CSHS receives 30% of the MCH block grant. CSHS is complementary to other programs in the Family Community Health Bureau since it provides services and follow-up to newborns and their families identified through the monitoring section including the newborn screening and hearing programs. The bureau will be filling the CSHS Section Manager position. Ms. Dotson requested advice from the committee about reorganizing and putting the newborn screening and hearing screening into the same section with CSHS. There are currently two task forces meeting one on newborn hearing screening, the second on newborn screening and genetic services. Because the governor has asked for limitations on advisory groups, the CSHS advisory group will now become a subcommittee to the Family and Community Health Bureau Advisory Council, however it will continue to focus on the work of Children Special Health Services.
Recruitment for New CSHS Section Supervisor (Jo Ann Dotson) The CSHS management position has been open a very long time due to budget problems. The position was closed once already, but there was only one applicant. The position is being advertised again and closes on February 15, 2006. The advisory group council has indicated that they would like someone hired with CSHS experience, but more importantly, the position requires leadership and management experience. The advisory council and staff would provide the expertise in CSHS to someone with management and leadership experience. The position requires a bachelor's or masters, grant-writing, budget and management experience. Ms. Dotson requested advisory group assistance in active recruitment. The fiscal position is also being reviewed and the bureau is considering other activities that Corliss, and others can share within the bureau. There are 82 clients in the direct pay and the budget is small enough so that there is usually a single person handling the budget. Dr. Guggenheim will give Ms. Dotson the name of an individual who would be a good candidate for the CSHS manager, but will give her the details confidentially. Salary is the problem since $38,000 is not enough to attract this person. The upper range is $47,000, but with approval the salary may be upgraded to as much as $50,000. Members of the management interview team will be: Jo Ann Dotson, Mary Anne Guggenheim, BJ Archambault, Debbie Henderson or another section manager, and Susan Gardipee. Applicants will be asked to do a presentation on Children's Special Health Services. The position closes February 15, the following week they will receive the applications for the review, and interviews will be scheduled a few weeks after that. They are hoping to have the position filled sometime in March.
Ms. Archambault will represent Montana CSHS at the association of MCH at the AMCHP meeting in Washington, DC in March.
Budget (MaryLynn Donnelly)-"The total working budget for FY2006 is $855,000 including unused funds from the FY2005 budget which carried over. The unused funds were in part a result of the vacancy savings for the section manager, but also due to cuts in family services. When the federal budget is appropriated there may be a total of $80,000 cut from the MCH block grant ($20,000 for CSHS). With the funds carried forward, there will be a one-time adjustment to put funding back into client direct payments and CSHS will increase the funding allocation for kids who may have already or will run out of funding for this FFY. Additional funding is also committed to the Missoula Pediatric Specialty Clinic to support Endocrine Clinics which are in danger of being cancelled. The other clinic sites will be reviewed for additional funding as available. The clinic sites also received an increase in the yearly budget for training of the clinic coordinators and computer hardware support. Ms. Donnelly will provide a line item analysis of the FY2005 budget for council members when it becomes available. The funding set aside for starting a Great Falls Pediatric Specialty Clinic Site was a biennial single time appropriation and will not be continued. Earmarked funding from the tobacco tax was not sufficient for the Great Falls Clinic Site due to less than anticipated tax revenue; therefore, CSHS might be better served with general funding instead of tobacco tax funding. A Bureau EPP request of $225,000 would provide $75,000 for each clinic site in the FY2007 budget, if it is approved at the department level. The EPP request includes clinic attendance numbers for the last five years showing increasing volume and will request general fund. If it is not included as a general fund request through the department, it can come in externally through bills in the legislature. The EPP process will take place in February and March. CSHS will inform the advisory council about the result of the process.
Team Billing Update (MaryLynn Donnelly) [Handout provided] Great progress!! There were questions regarding the numbers of children being seen in the cleft and metabolic clinics and the fact that most had some form of insurance and whether some children may be missed because they are not covered and not referred. Staff will provide the council with information regarding national statistics on the metabolic diseases and the state breakdown for the next council meeting. In most regions of the state, surgeons are referring to the cleft clinics, but the western region could show some improvement with referrals. There was agreement that there needed to be improvement in how children with metabolic conditions are found. Dr. Schlesinger suggested better benchmarks for metabolic clinic patients as well as a plan for doctor education on the clinics. There was discussion about whether it was money, referrals, lack of diagnosis or all three. There was discussion of the birth defect registry tracking of metabolic disease, but the state ran out of funding for the registry. Susan Gardipee said that there is a lack of information in the community and both family members and doctors don't know about resources and services. Suggestions for marketing of the metabolic, cleft and other clinics included a series of informative articles in the newspapers, blurbs in state medical association newsletters, and sending business cards with the clinic information to doctors. Dr. Byron suggested that tax write-offs for physicians providing clinic services would stimulate physician willingness to participate.
CSHS has adjusted its clinic-billing rate to $1,000 for team evaluation of a child with cleft/craniofacial or metabolic conditions.
Discussion: So if a conservative cost estimate is $1150-$1400, what should the rate for insurance companies be? There was also concern that if Medicaid agrees that the rate is $1000, then they will pay providers that have contracts, such as the hospitals, less than that. That is even truer of Blue Cross Blue Shield and other private payers. There was a suggestion of $1800 from Mary Anne Guggenheim and Peggy Schlesinger (who have run private practices). There was discussion of the charging and what was appropriate so that providers would make some profit. Ms. Archambault said that actual costs for Metabolic clinics to CSHS are $1400 not $1152. It was agreed that a billing concept for teams was a good idea and that payment was much better with companies because of this approach. CSHS is currently billing for the cleft and metabolic clinics and when the bugs have been worked out, CSHS will hand billing over to the facility sponsoring the clinics.
Other:
The Birth Defects Registry is no longer funded. It therefore needs to be revamped. John Johnson and MaryLynn Donnelly expressed interest in this. Birth defects can still be entered into the CHRIS system " so we can access the birth defects electronically. As part of this discussion, MaryLynn asked if the birth defects registry is reactivated, would it be within CSHS mission to send out a letter to families of children with birth defects giving them direction to appropriate resources including our department. It was agreed this was appropriate.
Goals: CSHS Activity Plan:
Great Falls Specialty Clinics (B.J. Archambault)-"The RFP for the Great Falls Central Region Specialty clinic site went out last week. Both Benefis and the Great Falls Clinic have been notified, but Benefis has indicated their involvement with an upcoming JACHO audit will preclude them from responding to the RFP by the CSHS imposed deadline. CSHS wants to start the clinics this spring at the GF site. The RFP is to be awarded March 1. The regional site will have to hire a professional nurse as clinic coordinator. CSHS will be involved with the hiring and will require the position be advertised outside the GF Clinic. The subcommittee members were encouraged to suggest nurses who might be recruited actively. Petra Messick will be the medical director. The Central Region Pediatric Specialty Clinics will be located next to the pediatric clinic at Great Falls Clinic. There were questions regarding access to the clinic by physicians not affiliated with the Great Falls Clinic. The cleft/craniofacial clinics will continue in Dr. Santin's office. The Great Falls Clinic will do the billing for the clinics. CSHS provides each regional clinic with basic infrastructure, computer, CHRIS software, on going training; staff support, but the regional clinics will take it from there. CSHS will reach out to the community and to WAMI doctors to be part of this. Several council members cautioned regarding CSHS being sensitive to the political issues within the Great Falls medical community.
Website (MaryLynn Donnelley)-"The CSHS website should be live on February 15. Dr. Nicholson said that PLUK has an approach to an integrated website that will include pages that medical/treatment communities could have on the site and update themselves. There was discussion that some of the information in the website handout regarding eligibility was outdated. Changes to the web format will include elevation of the specialty clinics above financial information, correction of the medical and financial eligibility, and changes to financial assistance. CSHS will send business cards to doctors alerting them about the website. Laura and Cyndi will talk with Roger at PLUK.
Eastern Region Pediatric Specialty Clinics (Cyndi Leaphart)-"Total numbers at the clinics are down slightly and some clinics have been discontinued. They are working with CSHS on billing, but the hospital does not allow them to do fee bundling even though they would prefer to. The clinic site has a new supervisor and a clinic assistant, but other nursing position was reduced to part-time and the 2nd nurse left. They have reduced costs by sharing space with another clinic, but will be moving again. The speech therapist for the cleft clinic is leaving. They conducted a survey of physicians regarding the clinics and received good response. Some suggestions for improvements were offered in the comments. NICU follow-up clinics are now being held; there was discussion about the high percentage of learning disabilities in children by age 2 in this population and the need for information to follow them through school. There was also discussion about the composition of treatment teams and the integration of cystic fibrosis and pulmonary clinics. Physical therapists, social workers, nutritionist are all considered vital members of the treatment team. Out-of-state physicians who do clinics receive payment of $2,000 a day, which was negotiated by the hospital without consideration of Ms. Leaphart's recommendation.
Western Region Pediatric Specialty Clinics (Ellen Carey) Missoula is offering a new clinic on hemophilia and thrombosis and is considering a pediatric GI and nephrology clinic. Some specialty pediatric physicians want as much as $3,100 per day, but they currently pay $2,100. The hemophilia clinic is grant funded so they don't have to bill for it. The hospital has been doing billing for out-of-state specialists and has a $10,000 YTD loss for the specialty clinics. The endocrine clinic is the largest. The cerebral palsy clinic was team-based, but has been changed to medical. The loss of the pediatric orthopedist has been a problem. It has been difficult to get a pediatric nephrologist due to the high cost.
Financial Support for Specialty Clinics (MaryLynn Donnelly)-"There was discussion regarding outreach to WAMI and teaching universities for specialists. There was more discussion of billing, bundling, and cost shifting to deeper pockets. This continued to discussion of an overall scheme to attract specialty physicians to the state. Because of the small population base and its distribution, it is difficult to support specialties unless a physician is willing to make less money. Dr. Schlesinger suggested that the state needs a different model so that there is a sustainable plan for these pediatric specialties. She would like there to be state-wide training of pediatricians so that they have some elementary training in specialties as 'hobbyists'. Dr. Guggenheim commented that the state is moving to the regional model, but maybe where certain clinics are concerned they should be held in only one place. It was suggested that more use could be made of tele-medical clinics, but they offer a special set of problems. Further suggestions were: asking Medicaid to help out with travel; asking drug companies to donate or help out with growth hormones for endocrine clinics; asking WAMI to help out with in-kind services in Great Falls; and asking LEND at University of Washington to help with projects.
Dr. Nicholson distributed a draft CSHS activity plan for 2006, and Ms. Donnelly asked that council members e-mail comments. The plan organizes CSHS activities into a framework based on program systems development goals. Ms. Scott will provide updated e-mail lists to council members. Ms. Carey suggested that they add something about health insurance for children transitioning into adulthood. CSHS funds can be used for children up to age 21 with diabetes and perhaps that could be extended to children with other metabolic conditions. Ms. Archambault suggested that they might try to expand CHIP to buy insurance coverage on a group policy for these children. Insurance and pre-existing conditions were discussed as well. CSHS will research budget impact of providing financial assistance to young adults with chronic conditions such as diabetes and cystic fibrosis up to age 23, rather than ending assistance at age 19, as is current policy. There was also discussion of how CSHS could help young adults from ages 19-23 to transition onto adult insurance, if needed. For instance if they have to pay for everything for a preexisting condition for six month or a year, CSHS would help them with medical expenses for that preexisting condition for that year.
CSHS asked for assistance determining funding equity for clinics and a subcommittee was identified. Members are Dr. Schlesinger, Dr. Johnson, Ms. Carey, and Ms. Donnelly.
Other Projects:
Survey of Parents of Children with Special Health Care Needs (Cyndi Leaphart, RN)-"The survey information is not ready. They received lots of calls from parents. Information is being compiled.
Metabolic Screening and Follow-up, (Mary Anne Guggenheim)-"The task force is considering expansion of the newborn screening menu and a system of immediate long-term medical treatment, assessment of care, and education of parents. There are 30 to 40 diseases that can be identified through newborn screening, but Montana screens for only five conditions. The infrastructure for long-term medical care would require state funding "to the tune of" $150,000 to $200,000 per year. If the task force can come to consensus, they will develop a plan for funding. The newborn screening money is being used to keep the state lab afloat. The next task force meeting will address the funding issues. If the task force does not come to any consensus on this issue, perhaps an administrative rule change or legislative action will fix this. Dr. Johnson said that the Shodair lab has extra funding with prospects of a tandem mass machine for metabolic screening___________.
Hearing Screening and Services Update (Laura Nicholson)-"Ninety-six percent of newborns receive the first hearing screening, but only five percent receive further treatment through the state. Ms. Leo wants the state to commit to hearing aids for all children who need them since it is cost effective over the long term. PLUK may be able to help with a project focusing on hearing aids, but the bigger goal is to get parents more involved and aware of available services. The parent-project work group is going to send out a survey to parents to identify needs. The success rate for cochlear implants is 60%, but children need intensive follow-up to learn to interpret sound as speech. UNHS program goals include screening by one month, diagnosis by three months, and hearing aid and intervention by six months.
PLUK and Family Voices (MaryLynn Donnelley)-"CSHS is contracting with PLUK for more parent involvement. See Activity plan for proposed activities.
Advisory Committee Business:
There will be a video meeting once a year and a face-to-face meeting once a year. The video conference will be in six months.
Laura Nicholson will remain as acting chair, Marian Kummer, MD will be the first vice chair, and Jerry Eichner will be the second vice chair.
Meeting adjourned at 3:10 pm.
