Flex Program Advisory Committee Meeting Minutes

Flex Program Advisory Committee

Meeting Minutes

Tuesday, January 15, 2013
10:00 a.m. - 12 noon

ORHPC Members Present: Judy Bergh, Tim Held, Anne Schloegel, Craig Baarson, Will Wilson, Rachel Gunsalus, Mark Schoenbaum, Darcy Dungan-Seaver

Committee Members Present: Maria King, Minnesota Department of Health-Compliance Monitoring; Frank Lawatsch, Swift County Benson Hospital; Karla Weng, Stratis Health; Judy Bird, Representative Walz’s office; Stacy Barstad, Sanford Tracy Medical Center; Rick Failing, Kittson Memorial Hospital; Gary Wingrove, Gold Cross Ambulance; Deb Teske (for Pam Biladeau), Emergency Medical Services Regulatory Board; Barb Heier, Tri-County Hospital; Ann Gibson, Minnesota Hospital Association; Joe Schindler, Minnesota Hospital Association; Karen Miller, Representative Bachmann’s office; Sharon Josephson, Representative Peterson’s office; Tracy Morton, National Rural Health Resource Center; Ray Christensen, University of Minnesota, Duluth; Lori Sisk, Sanford Canby

Guest: Gary Sabart, TSP Architects


  • Judy Bergh asked for guidance on how to handle membership for (1) those who have exceeded their membership terms; (2) those who are retiring; and (3) those who have left their positions and now are in another region. She described how this has been handled in the past with a nominations committee.
  • Rick Failing made a motion to return Brian Carlson as chair, in his role at Thief River Falls; unanimous vote to approve the motion.
  • For current and upcoming vacancies, Minnesota Hospital Association (MHA) will seek nominations from the upcoming MHA regional meetings. Judy Bergh will send list of vacancies for that and will also send updated list/status of all members to the committee.

Federal update

  • Mark Schoenbaum reported on upcoming federal budget milestones with sequestration only delayed and a continuing resolution set to expire on March 27. No budget yet for FY2013. This will need to be resolved.
  • He also described possible scenarios if sequestration occurs. The Office of Management and Budget (MMB) has sent a memo asking agencies to begin contingency planning. It’s not clear how Health and Human Services (HHS) would execute the cuts, but it could affect resources relating to CAHs, including SHIP and Flex. The president had earlier proposed eliminating Flex.
  • Gary Wingrove gave an update on federal EMS issues.
  • Ann Gibson reported that $170 million in cuts to hospitals is on the table. None are directly to CAHs, but proposed cuts to them do pop up, such as new mileage restrictions and a reduction from 101% to 100% cost reimbursement. MHA is working aggressively on these issues.
  • Mark Schoenbaum reported that all extender and add-on provisions, for all provider types, are on table.
  • Mark spoke about more proactive responses to CAH threats, including possible responses to the MedPac report that concluded Medicare was paying too much to CAHs and would not harm Medicare patients if those payments were cut back. National groups, like the National Organization of State Offices of Rural Health (NOSORH), are reviewing and developing responses.
  • Other key background points were discussed including Flex/CAH programs are now 15 years old, and much of the language of those programs doesn’t reflect the ACA and related reform initiatives. For example, the ACO Medicare features in the ACA don’t include Rural Health Clinics (RHCs) as providers. Physicians are determinants of assignation, and these are not necessarily primary care providers. Rather, it’s the provider with the most costs for a given patient, and this is often a specialty provider. It may not work very well for rural.
  • Gary Wingrove reported that MedPac also has an ambulance report coming out that draws similar conclusions. The final report is being held until later in the year.
  • Mark reported that NOSORH is working on various frames, including: (1) rural health systems are high value and (2) integrated services can come more easily in rural areas with the right incentives, payments, etc. When Eric Schell presented these facts to large health systems in the northeast, they decided to invest more in local rural areas than in their big tertiary centers.
  • Rick Failing suggested requiring MedPac members to watch a video that shows what an ambulance in a rural area sees through its windshield as it goes from the local hospital to the regional center.
  • Rick may need to define levels of rural, especially for those closer to bigger hospitals, versus those that are 40-60 hours away from one. Mark noted some of these distinctions between rural and frontier are getting attention.
  • Mark pointed out that another argument is that the more services can be bundled into a CAH, the lower the unit costs under the cost-based reimbursement system. The system is reasonable and can be used to lower costs elsewhere by spreading services across the fixed costs to lower unit costs. MedPac may not buy that, but it’s one argument.
  • Rick mentioned that perhaps the big accounting firms that work with CAHs could gather that information and it would carry weight with MedPac.
  • Mark pointed out that MedPac may not be the main influencer - Congress is. Judy Bird agreed that Congress is the final arbiter, and the message needs to be simple. It may be that examples like Rick’s earlier (a simple definition of needing to make sure emergency services are available everywhere) is the way to go.
  • Mark described federal demonstrations that bring additional services under the cost-based umbrella, including primary care and nursing. There is some talk of expanding such demonstrations.
  • He pointed out that we may need another name or variations on the term “cost-based reimbursement” system. He has more detailed materials and will share with the group. He also asked that members share any additional feedback.
  • Ray Christensen expressed concern on how best to talk to legislators.

Flex Program update

  • Judy Bergh reported that she has been doing site visits and recently also did a mock survey. She reminded members that she is always available to do mock surveys upon request.
  • ORHPC plans to do more community forums (as were done in spring and fall 2012). This time they will be held in southern Minnesota.
  • The Flex program is continually looking for advice on how to better serve the EMS community. The program offers grants and also supports trauma, but is also looking for ways to better support other EMS needs.
  • Flex grant award agreements are in process, with $254,800 being awarded. More than $589,000 in grants was requested.
  • Judy may try to increase the number of retired CAH CEOs involved in grant reviews along with others too. Always looking for volunteers to help with this process. The grant process may also go online in the future; possibilities are being explored.


  • A letter went out this week bringing hospitals up to date on Medicare Beneficiary Quality Improvement Project (MBQIP) an initiative out of the federal Flex program. She explained the background, including the Memorandums of Understanding (MOUs) most CAHs signed two years ago that give access to the Hospital Compare measures. Minnesota is unique in already doing a lot of this work, whereas many other states needed a lot of technical assistance.
  • Stratis is a key partner and will be doing the bulk of the work, including technical assistance to CAHs and confirming the validity of data, etc.
  • The next SHIP Request for Proposals will include a focus on MBQIP features/requirements.
  • The flow sheet handout shows how the process of review and potential QI initiatives will work.
  • Quality reports have been generated and will go out to CAHs soon, with their results benchmarked statewide and nationally.
  • Mark explained background on the program via HRSA/CMS. The next step is for them to ask CAHs to take a Quality Improvement (QI) approach “to move the numbers.”
  • Judy asked members to share thoughts on what types of QI initiatives would be helpful or areas where help is needed. More information will be coming soon, both from HRSA/ORHP and from ORHPC.

Minnesota Rural Health Conference

  • Planning is under way; save the date June 24-25, 2013.  Reminder that CAHs and Flex Advisory Committee members can be reimbursed for part of their attendance cost. Judy will distribute specific information as the date approaches.
  • RFP is out for breakout sessions, please consider applying; due date is February 1.
  • RFP for Rural Health Hero and Rural Health Team awards will come out later in the year.

Federal Flex grant

  • Waiting for guidance from feds for next round; due out in mid-March, with the application due in mid-May.
  • ORHPC will continue to have same broad areas of focus, but change some of the specific activities. Judy asked members to let her know of any they think we should be doing.
  • Will again include subcontracts, and ideas also welcome for expertise needed.
  • Will hear more when the guidance is out.

Meaningful use incentives

Craig Baarson announced that CAH II Physicians now eligible for the EHR Incentive Program. Incentive Payments begin in 2014.
  • Rick asked whether facilities that “own” their physicians, like Kittson Memorial Hospital, are ineligible for this and whether there’s been any discussion about that. Craig hadn’t heard but will look into it.
  • Mark stated that some say this reimbursement is a good move, but others say it’s a “day late and a dollar short” and that CAHs should have a way to get reimbursed sooner. He asked members to share any advice they might have on that.

EMS Toolkit

  • Rachel Gunsalus shared background on development of the EMS toolkit that will soon be released. This was an idea that came out of Rural Health Advisory Committee. She described its sections and invited ideas/feedback. Please send them to her or Judy.

Member updates

  • Maria King shared that she is working on new regulations for advanced directive and related issues. They have gotten workload assignments and CAHs can expect a compliance survey.
  • Frank Lawatsch spoke on building a new clinic which is larger than their old one. It should be done by September 2013. Also implementing a new OB program; old one was discontinued five years ago. Their nurse practitioner is getting c-section training and they’re looking for contacts to send staff for skills development.  Also looking for credentialing information. They’re also recruiting for one or two family practitioners.
  • Karla Weng reported that they are working on MBQIP and also developing webinars on hot topics in QI in CAHs. Also working on expanding pilot for community health needs assessment and recruiting additional communities. They are expanding the rural palliative care program. With a federal grant through the Rural Policy Research Institute (RUPRI) for health care reform, they’ll be helping rural health care providers through reform, especially around value. The REACH program continues.
  • Stacy Barstad reported on the recruitment for two midlevels, which has been a struggle. They also have outreach vacancies. Keeping up with the flu. Mark noted that Bethel is starting a nurse practitioner program. Barb suggested looking at the bulletin the AAFP  puts out.
  • Rick Failing expressed concern about Blue Cross/Blue Shield (BC/BS) changing reimbursement, going to Diagnosis Related Group (DRG) system vs. old “C” hospital reimbursement based on charges. Difficult for small facilities based on small volume. Discussion whether others have received this notification and whether limited to the northwest region, perhaps related to similar complaints from North Dakota providers. The Minnesota Hospital Association is looking into this change from BC/BS. One concern is hospitals aren’t being told what the new rate is. Looking into possible legislation to address.
  • Rick Failing also mentioned another concern relating to legislation passed last year on accreditation for advanced diagnostic imaging. A November 2012 bulletin from MDH said they need to be accredited too, though the hospitals’ understanding was this was targeted to stand-alone centers. This is challenging for his facility. The MHA is working on this issue.
  • Ann Gibson reported that MHA will be in DC next week. Also working on workforce issues and how to deal with clinical placements; which is in the early stages.
  • Karen Miller, Rep. Bachmann’s office, had no update, but wished to express her thanks for everyone's efforts.
  • Gary Wingrove reported that community paramedic activities are moving along. He mentioned presentations given to federal agencies and work done with an international paramedic group that talked about possible World Health Organization (WHO)/United Nations (UN) initiatives.
  • Debbie Teske, Emergency Medical Services Regulatory Board, reported that Pam Biladeau will be presenting this week to a House committee. Working with community paramedic folks. Doing strategic planning and looking at the impact of health care reform on EMS and the people they serve.
  • Ray Christensen mentioned that first-year students are being sent around the state to rural hospitals and clinics. He expressed his thanks for making them feel welcome which is so important.
  • Sharon Josephson expressed concern about the federal budget/finances, and also about violence, including how to ensure adequate psych services in rural areas. She will work to encourage folks in congress/legislature to participate in these sorts of discussions.
  • Gary Sabart (guest) described two CAH projects that they are working on.

Next Meeting
Joint Flex Advisory Committee and Rural Health Advisory Committee meeting

May 21, 2013
10 AM—2 PM
Location TBD

Cindy LaMere and Judy Bergh are in the process of scheduling the remaining meetings for the year. Due to the loss of our lease at the Snelling Office Park (where meetings have been held), we are seeking another location. Once a schedule and location are determined, information will be sent out to the membership and also posted on the Flex website.


Flex Grant Awards 2012-2013:(PDF:68KB/1pg)
MBQIP Data Report Flowchart December 2012:(PDF:129KB/1pg)
CAH Method II Physician Participation in the Medicare EHR Incentive Program Fact Sheet January 2013: (PDF:88KB/1pg)

Updated Wednesday, March 19, 2014 at 12:25PM