West Virginia Rural Health Education Partnerships/Area Health Education Centers

West Virginia Rural Health Education Partnerships/

Area Health Education Centers

 

WV Rural Health Advisory Panel Meeting

Days Inn Hotel, Flatwoods, WV

Monday, June 15, 2009

Chair: Dennis McCutcheon

 

Voting Representatives in attendance: Dennis McCutcheon, Jill Cochran, Alison Witte,

Anna Reno, Shirley C. Neel, Grace Mitchell, Tom Hefner, Sharon Hanna, Mike Callaway, Sandra Elza, JoAnn Raines, Dave Brown, Richard Meckstroth, Georgia Narsavage, Carla See, Robert Walker

 

Guests: Lora Adkins, Malinda Turner, John Walters, Christy Rogers, Kathryn Greenlief, Rhonda Carpenter, Sonnie Stader, Crystal Welch, Carla Campbell, Sarah Adkins, Lew Holloway, Parr Thacker, Amber Crist, Elizabeth Richmond, Ralph Utzman, Eric Shaw, Patricia Crawford, Amanda Heaton, Alicia Tyler, Robert Foster, DO, Jim Arbogast, Jay Prager, Violet Pastorial, Connie Simmons, Chuck Connor

 

Staff: Hilda R. Heady, Sandra Y. Pope, Sharon Giles, Margaret Novacich, Jodie Jackson, Kimberly Robinson, Rose McCluskey Jacki Novacich

 

Meeting was opened with introductions of those in attendance.

Motion to approve Consent agenda (Carla See/Anna Reno) Motion Approved.

 

New Business:

Policy Approval: Policy 2004-02 (revised)- Distribution of Medical Student Rotations to Shortage Areas

 Jodie Jackson gave a brief overview of the changes made to the policy.  The Policy was brought before the Panel for approval.  Motion for approval of Policy 2004-02 (revised) (Dave Brown/Tom Hefner) Motion Approved.  Policy will be changed to Policy 2004-02 (rev. 6-15-09).  Jacki Novacich will send a final copy to Dr. Walker and Hilda R. Heady for signatures.

 

Committee Reviews and Group Reports: Finance Committee - Grace Mitchell, Chair of the finance committee reported to the panel that Fiscal Analyst Kristi Pritt, has taken a different position with HEPC and has been replaced by Beth High.  Beth is working with the program on a part-time basis.  She also reported that WVU School of Nursing is requesting RHEP funds for  travel reimbursement for students.  This request was tabled until more information could be obtained from Dr. Narsavage, Dean of the School of Nursing.  Hilda R. Heady will meet with Dr. Narsavage to review information regarding this request. 

 

Vice Chancellor's Report: (the following is a transcription of the recording of Dr. Walker's report.

Several reports were commissioned by Higher Education Policy Commission (HEPC) focusing on WV Rural Health Education Partnerships (WVRHEP).  They have been circulated and taken under advisement.  The panel and partnership was directed to consider challenges, opportunities, strengths and weaknesses pointed out in the reports and work to improve the program based on these recommendations..

 

Friedland Report and Staff Comments: The Friedland report was conducted by Dr. Michael Friedland at the request of Dr. Brian Noland, Chancellor for WV Higher Education Policy Commission (WV HEPC).  The report was developed to determine if a quality medical education could be obtained in rural areas of West Virginia.

Dr. Michael Friedland is a long time medical educator that has participated in many accreditation bodies for medical education.  He was also a Vice President at West Virginia University and founded the Eastern Division Campus.  Dr. Walker stated that a lot of time was spent going through the phases of RHEP proving that there was available quality education out there. This report was not a report intended to focus on RHEP, but to focus on medical education in West Virginia. Data was gathered relying on various data sources.  What was discovered was that we may not have a shortage of physicians, but there is a significant mal-distribution.  The trend shows that over 5 years time there was no recruitment of physicians to sixteen counties, and in that 5 years we recruited, on average, 1 to 2 students in another sixteen counties.  The problem lies in the fact that some of the counties have low population but others may not.  Dr. Walker stated that "the standards to which we will be held is not just are they rural, but what are you doing with those areas that are more difficult."  Those counties are challenged in many ways that go beyond education and educational preference.  WV is 3^rd in the number of medical students that graduate per capita and that is a big investment.  The number of students has increased from about two hundred students in 1991 to about five hundred students in recent years.  We have also seen a decrease from 90% of those students being in-state to 40% being in-state.  Whatever we do with the development of this program and however we proceed, we will have to recognize those changes.  He also noted that he has seen a change in the teaching environment.  He has talked with some physicians and they reported they were under a lot of stress with electronic medical records, changes in  Medicare requirements and, regulatory changes, etc.  In some cases, this may impact their ability to teach due to the time restrictions and loss of energy.  Legislators care about the possibility that qualified West Virginians are not accepted to state medical schools and their places are given to equally qualified out of state students.  Dr. Walker believes we can assure them that this does not happen. 

Another point of interest in Dr. Friedland's report is resident training.  Eighty percent of students/residents who train in primary care in WV will result in only 15% who are still in WV 5 years later.  We are aware that it is a self selected movement, but we need to make sure there are enough primary care residency positions available. 

We have had a great increase in out recruitment of doctors that are from WV.  The percentage of WV medical graduates practicing in rural areas remained relatively flat from 1981, pre-RHEP, to 2006, with the last tracking cohort year at approximately 11% per year recruited. 

One issue that comes up is that of medical school accountability and accreditation.  We have talked about this to some extent.  There has been some concern over the years that the perception is  that accreditation  is not controlled by faculty and administration in the individual medical schools.  The accrediting standards now are pretty firm on administration and faculty  having control over the curriculum and specialist required course load.  Course load is strongly linked to immediate decisions by faculty and administration and there we get into some semantics.  The Friedland report made some recommendations that will be taken into consideration.  One consideration is; is it still the best pattern to have every student do a number of months versus selecting a small group of students that show interest to do a concentrated rural rotation?  We could focus on a smaller group of students.  Dr. Walker indicated he felt that we may not have the capacity to do what we are doing now with class sizes increasing. 

 

Questions were raised from panel members including validity of statistics and recommendations.  Some felt that not enough people were interviewed to support the findings. 

 

Carla See from WVU School of Pharmacy indicated that she hoped any decisions made based on the reports would involve input from all partners, especially the communities.  Ms See said that she had a concern that people who don't understand RHEP, or see the value of what has been brought to rural communities in WV, are going to be making decisions to determine how RHEP  will look in the future. She also urged the decision to be based on data and outcomes of the program. 

 

Dr. Walker stated that it was a good concern and it is a concern in every public issue in WV.  He went on to say that the Legislature is the one who makes the decisions. 

Tom Hefner (Panel member and Board member from Northern WV Rural Health Education Center) questioned, "What is the next step?"  Dr. Walker stated that we would be getting to that point shortly.

 

Suttle & Stalnaker Report on Agreed Upon Procedures: This report was commissioned by the WV Higher Education Policy Commission to analyze the organizational structure of WVRHEP. 

Some concerns from this report are accountability, confusion as to who is accountable, or who is in charge, liability issues, and difficulty tracking funding and personnel.  There has been huge changes in not for profit requirements and it is generating greater scrutiny.  We have to be very aware of accountability in a public policy sense in order to protect everyone.  The lead agency is the entity liable for the consortia's finance/budget since it is the formal  contractor  with the state. 

 

Hilda R. Heady stated that there have been discussions on liability in the past.  BRIM worked with HEPC and they looked at the structure of the boards.  It was determined that all boards were protected, as long as they had a representative from the lead agency that was either the Administer of the lead agency or the CEO, and they were approving the budget, and the CEO and CFO had knowledge, that this was acceptable.  It was through that avenue that the liability question was answered and that is why BRIM went through the process to issue a certificate of insurance.  If in fact that has changed, we need to figure out a way to improve that. 

 

Sandra Elza, CEO of Jackson General Hospital, lead agency to Winding Roads Health Consortium, stated that they just went through the process recently, and were told that as long as there was no intentional misappropriation of funds or wrong doing, they were covered.

Dr Walker stated that one liability issue option was for medical education or some state agency to receive the state funds and to  then disperse the funds out.  This does not change a lot.  He went on to state that "Personally, there is a lot of confusion about responsibility and roles."

 

The Pathman Report "Summary Observation of Data on Where West Virginia's Physicians Trained as Medical Students and Where the Graduates of the State's Medical Schools Practice Seven-to-Ten Years After Graduation.": The Pathman report was to look at trends of total number of physicians, number of physicians in primary care, and number of those in rural areas.

Dr. Walker discussed the report by stating that it is interesting and technical as it covers recruitment and retention in WV.  According to the report, WVSOM has done very well.  The report does not state that RHEP is not working.  Dr. Walker agreed that RHEP has been successful but he felt  that RHEP  can do better in many areas.  He further stated that he felt if the state were to place 60 students in a special program, and focus intensely in rural training on those 60, that potentially 45 of them could be recruited to much needed areas of the state.   

There are many factors such as an increase in student numbers, a big expansion in loan forgiveness programs, and improvement in medical malpractice issues, that need to be considered..   

 

Hilda R. Heady stated that we tested the consistency issue by comparing the data entered into tracker and the data that Don Pathman reported.  The Pathman report shows 13% for the graduates who finished school between 1996 and 1999 were working in WV.  When we ran the same data, we show 12%.  The outcomes are similar and that gives us confidence in what we report from the Alumni Associations and what we verify from the field.

 

Dr. Walker went on to say that we need to find a way to recruit to those 16 counties that show little to no recruitment and retention. 

 

Jodie Jackson (WVU Office of Rural Health) stated that in our 2008 R&R report we show only 7 counties that had no RHEP graduates retained. That is a big change from 2004. 

 

Dennis McCutcheon (Chairman of the WV Rural Health Advisory Panel)  asked Dr. Walker, "How will these reports be used and what are our next steps?"

 

Dr. Walker indicated that they will be used by HEPC in their decisions regarding the future changes in the program.  The reports will be used to provide some guidance as we move forward.

 

A question was asked from the floor regarding whether data from the Pathman report was compared to other rural states?"

 

Dr. Walker stated that it was compared to Vermont, but it is hard as Vermont is a very different state than WV demographically.

 

Hilda R. Heady went on to state that one of the things we want to talk about is the possibility of doing the same thing and comparing those to other states and seeing what it would show.

 

Someone from the floor suggested that we find a state that is predominantly rural, that has a requirement for rural rotations, and possibly has an osteopathic school, and see what the trend has been over 10 years.

 

There was a question from the floor inquiring if there was going to be a deconstruction of the program.

 

Dr. Walker stated that at this time, he did not know.  He said he felt the investment in RHEP is not lost.  We need to look at potential changes and look at the future and how this is going to evolve.  It may be we have to look at things with half of our students coming from out of state.  Unfortunately, we do not know how many of those we are going to retain.  That is the big issue.  On the other hand, these out of state students have enormous debt and that was not true years ago.  That is another huge change.  Their support systems are often still in their home states.

We need to look at all those things and the policies and implications and predict as best we can what will happen, as well as factors such as program excellence.  The solution for 1999 is not the solution of 2009.  We need to evolve not throw away.  If we lose this program, we will not get these monies for rural health for a long time.  We need to look at how we teach and maybe not do a 2 or 3 month rotation for every medical student.  This may mean looking at, for example, 60 students with special attributes in which we focus a lot of resources.  Dr. Walker indicated he was not sure what would happen with other disciplines in the program but he felt it might be best to focus on fewer medical student rotations in order to increase the percentage of doctors recruited to the state.

 

Dr. Walker stated that the Post Division Audit, or what is known as the Financial Legislative Audit, would be available soon. This report will be an additional source of data that will be referenced  in  the coming months.

 

Hilda inquired about the RHEP Legislative study, and if we know where they will direct the questions or what the questions will be?

 

Dr. Walker stated the HEPC is not sure at this moment and only that they are to be studies at monthly intervals.  He indicated that he did not think the program was in any trouble with its basic funding though.

 

Tom Hefner stated "I am a little confused.  Are these reports going to be unilaterally addressed by HEPC and recommendations made to the Legislature for changes in code or new policies issued; or will this advisory group or a sub group of the panel be involved to assist you as is our duty and function within the code?"

Dr. Walker replied "The Advisory Panel will be involved if we are given that luxury.  I think the Legislature will yield to this committee and me, and the Chancellor will essentially approve.  Whatever we do, we have to please the people, which mean their representatives.  We are foolish to displease the people or representatives, as well as, the medical schools themselves.  It is a complex issue that has been very skillfully done in the past.  I think the program will be ok.  If it is me doing that, I will try to convince you to change things; and if you refuse, I do not know what we will do.  I am not the kind of person who does it anyway."

 

Executive Director's Report:

Hilda R. Heady reported that there is a request that is to be brought before the panel, but will have to be tabled until the September Meetings.  The request is made by John Walters, Coordinator of Northern WV Rural Health Education Centers Region I.  The request is to remove the city of Weirton from the restricted rural rotation cities list.  The Schools Committee discussed this issue at their meeting today.  Dr. Foster reported to the Advisory Panel that the Schools Committee is in favor of the removal.

Material will be mailed to you in the September consent agenda packets.

 

Hilda went on to report that the Legislature closed out their session without passing the state  budget.  A special session at the end of May was held for the passing of the budget.  The AHEC line item placed in the budget by the Governor was zeroed out in the final hours of review.  The money was placed in the line item for Rural Health Outreach Programs, and is to be divided evenly among the medical schools.  Each school will receive $200,000.  The future of AHEC at this time is unclear.  We will not know the federal funding amount until the middle of August.  Sandra Pope and her office is developing various scenarios reflecting multiple levels of possible AHEC funding..

 

Sandra Pope reported that the National Rural Health Association (NRHA) is accepting applications for next year's class of Rural Health Fellows.  Jill Cochran, one of our field faculty and Panel members, was in last year's Fellow's class and reported on her experience at the February meeting.  Also, the planning for the 2010 NRHA conference is underway.  Session submissions will be due by August 1, 2009.  She will send out a reminder by e-mail. 

 

Motion to Adjourn: (Carla See/Sandra Elza) Motion approved.