WEST VIRGINIA HEALTH CARE AUTHORITY
PRIVATE OFFICE PRACTICES
CON STANDARDS MEETING
11/20/2008 – 1:00 pm EST
Conference ID # 137202
Ms. Sonia Chambers: My name is Sonia Chambers and I’m Chair of the West Virginia Health Care Authority. With me I have Sam Kapourales, board member of the Health Care Authority, and I’m guessing Marilyn White is on the phone?
Ms. Marilyn White: I’m on the phone.
Ms. Sonia Chambers: Great. This is the last of the scheduled meetings looking at some of the specific issues related to Certificate of Need and whether those issues should continue to be reviewable. As you all know, we have been going through a…the Legislature is looking at the issue of Certificate of Need in general and we had agreed to hold some more specific meetings to allow different parties to have input into the issue. We have had a series of meetings around different specific provisions in the Certificate of Need. In this one we are going to look at the issue of the Chapter 30 or private office practice exemption from Certificate of Need. One, whether it should continue and two, exactly what that means, because we’ve had a whole series of issues come before us recently that call some of that into question. Why don’t we go around the room here in Charleston and then whoever is on the phone and then we will open it up…well, we’ll actually have the Health Care Authority legal staff explain the issue and then open it up for comments. So again, I’m Sonia Chambers and Sam here.
Ms. Marianne Kapinos: Marianne Kapinos, General Counsel, Health Care Authority.
Ms. Cindy Dellinger: Cindy Dellinger, Assistant General Counsel to the Health Care Authority.
Mr. Jim Thomas: Hi, Jim Thomas, Attorney with Jackson Kelly.
Mr. Ed Hamilton: Ed Hamilton, Mountain State Blue Cross/Blue Shield.
Ms. Jill Vance: Jill Vance, Dinsmore & Shohl.
Ms. Bob O’Neil: I’m Bob O’Neil at Dinsmore & Shohl.
Mr. Evan Jenkins: Evan Jenkins with the State Medical Association.
Ms. Amy Tolliver: Amy Tolliver with the State Medical Association.
Ms. Raymona Kinneberg: Raymona Kinneberg with Bill Crouch & Associates.
Ms. Sheila Kelly: Sheila Kelly with the Certificate of Need division.
Ms. Martha Morris: Martha Morris with the Consumer Advocate’s Office.
Mr. Tony Gregory: Tony Gregory with the Hospital Association.
Mr. Bob Gray: Bob Gray from the Thomas Health Systems.
Ms. Kay Myers: Kay Myers, Health Care Authority.
Ms. Sonia Chambers: Okay and on the phone?
Mr. Phil Wright: Phil Wright, CEO of The Health Plan.
Ms. Angela Swagger: Angela Swagger with WVU Hospitals.
Mr. Bob Coffield: Bob Coffield, Flaherty Sensabaugh & Bonasso.
Mr. David Jarrett: David Jarrett, CAMC.
Ms. Nancy Vest: Nancy Vest, WVU Hospitals.
Ms. Marilyn White: And Marilyn White with the Health Care Authority.
Ms. Sonia Chambers: Anybody else? Okay, all right. I don’t know, Marianne, Cindy, both of you?
Ms. Marianne Kapinos: We’re going to do a joint presentation. I thought I would start out with just giving a little bit of history and background on the private practice exemption from CON and Cindy’s going to talk more about the legislative rule that we have, so obviously the private office practice of a health professional has historically been exempt from CON unless that professional acquired, offered, or developed major medical equipment and the threshold currently for major medical equipment is two million dollars. As private practices continue to grow and become more sophisticated and diverse, it became more difficult to draw the line between a health care facility, which is subject to CON review, and a private office practice, which is not, so in 1992 the Legislature amended the private practice exemption in the code and since that time certain services, regardless of their capital expenditure, have been subject to review if they were offered, acquired, or developed by a health care professional. The services specifically listed in the code are ambulatory surgery, lithotripsy, MRI, and radiation therapy. That code section also gives the Authority the ability to do legislative rules to further specify what services are subject to review and we have done that, initially in 1992, and then more recently in 2007, so currently the services that are subject to review under this provision are the ones I just listed, as well as end stage renal dialysis, PET, cardiac cath, birthing centers, diagnostic centers, and CT. Now the legislative rule part.
Ms. Cindy Dellinger: And just to follow up on what Marianne said, the statue gives us the right to promulgate the legislative rule, which is found in 65CSR17, and most of the people in this room are familiar with the rule and this rule applies to health professionals…
Ms. Sonia Chambers: Did we have somebody just join us?
Ms. Pat Woods: It’s BMS.
Ms. Sonia Chambers: Okay, great.
Ms. Cindy Dellinger: This rule 65CSR17 applies to health professionals licensed to authorize and organize pursuant to chapter 30 of the West Virginia code and it sets forth the health services, major medical equipment, and facilities which when acquired, offered, and developed are subject to Certificate of Need review. And the first part of this rule defines the diagnostic center and a diagnostic center is defined under Part A as any private office practice which offers laboratory or imaging services in which the total cost of laboratory or imaging equipment exceeds two million dollars. Part B says any facility whose primary purpose is to offer laboratory or imaging services. This includes offering the imaging services through an entity which derives more than 25% of its gross revenues from such laboratory or imaging services and this is regardless of the cost of the proposal, so there’s no cap with respect to subsection B. Subsection B is any facility which offers laboratory or imaging services to patients that are sent by other licensed health care professional for purposes of obtaining the laboratory or imaging service, so that’s the referral piece that we talk about and that’s also regardless of the cost of the proposal. There is one caveat with respect to this piece and that is you’re not considered a diagnostic center if the procedures that you perform do not trigger 25% of the total laboratory or imaging procedures that are done at the facility, so there is a small amount of imaging referral procedures that you can perform there. Under subsection D, any facility which offers laboratory or imaging to patients and is not organized as a sole practitioner, a partnership of licensed health professionals, or a professional limited liability company, is also considered a diagnostic center regardless of the cost of the proposal. Subsection E, a facility which offers laboratory or imaging services to patients through an entity for which any owner, for instance, spends less than 75% of his or total time spent on patient care services is considered a diagnostic facility, again regardless of the cost associated with the proposal. And then a facility licensed by the Office of Health, Facility Licensure Certification, or Joint Commission is considered a diagnostic facility and when we amended this rule there were certain grandfathering positions that we permitted to be included, so there’s certain provisions that were included in the legislation and then as Marianne said, there are certain services that are listed at the end of the rule that she enumerated, but I won’t go into, that if are offered trigger reviewability, as well. And then there are certain examples that we discussed. Do you want me to go into those?
Ms. Sonia Chambers: Just briefly, as examples of issues that have come before us recently.
Ms. Cindy Dellinger: There’s some examples that relate to scope of practice that we’ve encountered recently. For example, there was a physician assistant that brought a letter of intent to open an urgent care facility and so this relates to scope of practice that we’ve had issues with. A radiology technologist wanted to acquire some diagnostic equipment recently. We have had a respiratory therapist that wants to offer a sleep lab. We’ve had a registered nurse that wants to offer a sleep lab.
Ms. Sonia Chambers: And so the issue with those, Cindy, is whether those applicants could seek the chapter 30 exemption from review?
Ms. Cindy Dellinger: Right. It’s a scope of practice issue. They want an exemption because they’re chapter 30 practitioners, so it’s a scope of practice issue and then in terms of ownership issues, we’ve had a private equity firm being involved in the ownership chains of urgent care centers that are owned by private practice physicians, so that’s a recent ownership issue that we’ve had to look at.
Ms. [??] [??]: I’m sorry to make you do it, but could you go through that list again? I just wanted to make sure I understood. You had the PA and…
Ms. Cindy Dellinger: Yeah, we have a physician assistant that filed a letter to open an urgent care facility and then we had a radiology technologist that wanted to acquire some diagnostic equipment and then a respiratory therapist wanting to offer a sleep lab and then a registered nurse wanting to offer a sleep lab and then in terms of ownership issues we’ve had private equity firms being involved in ownership chains of urgent care practices with…an urgent care center that was owned by a private practice physician group.
Mr. Phil Wright: Question…what were the decisions on those issues?
Ms. Cindy Dellinger: Well, the first one, the PA withdrew the application. The radiology technologist, we eventually determined that was not reviewable because the person was going to basically serve as a mobile vendor of that. From my recollection he was not going to be offering the services, he was going to be providing the equipment. He wasn’t going to actually be a service provider and then the registered nurse with the sleep lab we determined was reviewable. We determined that that was not entitled to an exemption.
Mr. Phil Wright: And the urgent care?
Ms. Cindy Dellinger: And the respiratory therapist we determined was reviewable and I believe they said that they were requesting reconsideration on that and that reconsideration is currently pending, because the respiratory therapist is claiming that they’re entitled to an exemption under chapter 30, so that’s still pending in front of us. And then the ownership issue, we determined that that was entitled to an exemption because the private equity firm was so…the way it was structured it was so far up in the ownership chain in the way it was structured that the private physicians controlled the decision making that it was a private practice.
Mr. Phil Wright: So it was exempted?
Ms. Cindy Dellinger: Right.
Mr. Phil Wright: That was Med Express wasn’t it?
Ms. Sonia Chambers: Yes.
Ms. [??] [??]: The sleep lab, the RN offering the sleep lab that wasn’t reviewable and then where is that in the process?
Ms. Raymona Kinneberg: The application was filed. The decision has not yet been issued.
Ms. Sonia Chambers: Is that your client, Raymona?
Ms. Raymona Kinneberg: It’s the client of our firm.
Ms. Sonia Chambers: The client of your firm, okay. Okay, so that’s kind of an outline of the current status and some of the issues that have come before us, so I’m just going to open the floor for discussion. What we have traditionally done is gone around to everybody who’s participating and said whatever you’d like to say, we’d be happy to hear. So we can start…I can just start over here to my…oh, Raymona doesn’t want to start today. I suppose we could give Amy and Evan Jenkins the opportunity to go first if they’d like.
Mr. Evan Jenkins: I’m happy to….probably folks are curious where we would be on it. I think number one, I appreciate the Health Care Authority’s efforts in this review process. Two, obviously with the fair amount of scrutiny in this particular area over the last two years and with the legislative reforms to this particular rule and the occlusion of the CT to it, there were obviously some substantive changes in the rule relating to referrals and things like that. To date, I have not heard any outcry about some particular changes that were made on the referral and some of this other. I think we are, from the State Medical Association perspective, interested in continuing to monitor and see the actual implementation and as we get into issues of the CT, periodically we’ve inquired about what applications have been submitted for the many CT’s and I understood we’ve had one or two that were authorized. We’re certainly interested, also, in kind of the role and the posture of the Health Care Authority and over the one, two, and three years relating to the tracking issues and how the Health Care Authority has, while certainly not overly enthusiastic about all the elements that were in the modifications, I think in general we don’t come, at least at this point, with a laundry list, so to speak, of what we would call high priority recommended changes, but that’s not to say that modifications won’t be suggested and we may make some. Of particular interest is us to reiterate, I think, the general philosophy that the view is that statutorily, and except for this one area, generally the private physician offices are exempt and our biggest concern that the creep effect, so to speak, that the rules and other mechanisms will be used to kind of encroach upon that independent physician practice, so our interest here today as much to hear also from others is from a defensive standpoint to see if there is a concerted effort to try to use this mechanism to appeal to the Health Care Authority suggesting that more regulation is needed and that standards ought to be tightened, so I want to make sure it’s clear that we certainly are not supportive of the suggestion that this mechanism should be used to broaden the role in the government and the oversight of the Health Care Authority into the private physician practice, so let me summarize. One, we’ve been through a lot in the last couple of years. Two, we understand that to the extent possible there was a balance tried to be struck. We are anxious to monitor and see the actual implementation and how this kind of shakes out. Three, we want to make sure that we don’t see an effort to try to keep the ball rolling to broaden the regulation, the oversight.
Ms. Sonia Chambers: May I ask a question about your…one of the things that I think…again, I don’t think anyone has come to us suggesting necessarily that this exemption change. It’s more a matter, as we were going through the process, of looking at discreet areas, this was one of them, and it particularly came to our attention because of not the exemption itself, but who is covered under that exemption, as Cindy outlined, has come to our attention most recently and I guess my question would be…and I believe State Medical actually got involved in one of the issues that was before us, so I would be interested in whether State Medical has a position on what kinds of entities ought to be covered under the chapter 30 exemption.
Ms. Amy Tolliver: Our involvement in the one, and for the notes it was the PA opening the urgent care, and we weren’t raising a concern that a PA isn’t included under the exemption. We were raising the concern regarding the scope of practice of the PA and the operation of that urgent care and then management of the employees of that urgent care and we understood the way it was structured was that the PA was the owner, operator, manager with the hiring physicians, supervising this physician’s work, and then also would be working within that facility, so you have your hierarchy of a PA as a physician assistant, that PA is actually hiring the physicians, and we found great concerns with that structure, so we weren’t necessarily raising the issue of that they aren’t included as an exempt professional, but it was the way they were trying to structure their entity.
Mr. Evan Jenkins: Let me supplement that and say the first line of defense we thought was the Medical Practice Act and that was the Board of Medicine and the definition of what a medical corporation is and who must be…how is that [unintelligible]? If you’re going to practice medicine you do so under the Medical Practice Act and you do so in a corporate structure as defined by the Act and clearly this approach in this particular case did not meet that statutory definition, so our first challenge was really to the Board of Medicine and it was out of almost, I hope this isn’t the wrong word, that awkwardness of the Board of Medicine, well they’re not a medical corporation because they don’t meet the definition. Therefore, we don’t have anything to do with it now. That’s my language, not theirs and the petitioner or the person seeking to open up this then comes to the Health Care Authority and, I think, tries to use the Authority to be their springboard into being able to open this urgent care facility and filed an application for a CON towards that, so I think almost by default they were seeking some authority to do what they wanted to do and we felt that…and so our raising the issue was not that we thought this was the right venue for them to even be discussing it. We wanted to preserve our…we wanted to raise our voice, but we felt the bigger question was at the Board of Medicine level and we were hoping to engage them and think possibly could have had the filings not been withdrawn.
Ms. Amy Tolliver: And not to speak for the Board, but once we did engage them they were recognizing the same issues that we were and they were reviewing it.
Mr. Raymona Kinneberg: If I can add something here, because this goes back to the respiratory therapy and sleep lab which is, from our perspective, a very similar situation where you have a sleep lab owned by a respiratory therapist who is hiring the medical director, but is in charge of the operations and hiring staff and I think that based on our filings with the Authority, it’s a similar kind of situation where the respiratory therapist does not have that scope of practice. It’s a physician scope of practice and he doesn’t own the center and that decision is still to be issued. Oh, I’m sorry, I take that back. That decision was issued, it was found reviewable, and they appealed and requested reconsideration, and the reconsideration decision has not been issued. We see that as very similar.
Ms. [??] [??]: The radiological tech…I mean the other one…that was non-reviewable?
Ms. Sonia Chambers: But it’s a bit of a different circumstance.
Ms. Cindy Dellinger: In that situation the person wasn’t going to be providing a service. The person was going to be acting as more of a mobile vendor and was going to go to a facility and allow someone else to provide the service there.
Ms. Sonia Chambers: They were going to own the equipment and drive it around.
Ms. Cindy Dellinger: Drive it around and not actually provide the service and it was going to be available in a service area where it would otherwise not be available to people that needed the service.
Ms. Raymona Kinneberg: It is my recollection that you said it was going to be in docs offices and hospitals and they would be the provider.
Ms. Cindy Dellinger: That was in a medically underserved area and that is a different…it wasn’t going to be a service provider.
Mr. Jim Thomas: So in that case the billing would be done by the provider.
Ms. Cindy Dellinger: I believe. We asked a whole series of questions and it’s been awhile since I looked at…
Ms. [??] [??]: It was. I do remember that.
Ms. Cindy Dellinger: We asked all these questions at the time. He wasn’t going to provide the service and I don’t believe he was going to be doing billing for the service. He was just going to actually make the equipment available to the provider of service, as I recall.
Ms. Sonia Chambers: Mr. O’Neil, Ms. Vance.
Mr. Bob O’Neil: I don’t have anything.
Ms. Sonia Chambers: Just happy to be here today?
Ms. Jill Bentz: Yep, we’re just happy to be here to see everyone’s face.
Ms. Sonia Chambers: Mr. Hamilton.
Mr. Ed Hamilton: Okay! First of all I want to say we’ve got a fine set of regulations here.
Ms. Sonia Chambers: And what do you mean by that?!
Mr. Ed Hamilton: I do have a couple of questions.
Ms. Sonia Chambers: Clear as mud, huh?
Mr. Ed Hamilton: Major medical equipment. Where’s the definition for that?
Ms. [??] [??]: 16-2D-2 in the West Virginia code.
Mr. Ed Hamilton: Okay. Is it rigged at two million dollars or is…
Ms. [??] [??]: I don’t know what you mean by rigged, but it is two million dollars.
Mr. Ed Hamilton: It’s set in concrete, can’t change it, can’t raise it or lower it?
Ms. [??] [??]: Not unless the…it’s legislative.
Ms. Sonia Chambers: That is a statutory…major medical equipment is defined. I’m sure there is a definition…
Mr. Ed Hamilton: Well I didn’t see it in this copy, so I just wanted to check to see where. Okay, next question. When we look at 65, series 17, paragraph 2.1b and 2.1c, we see some guidelines, some requirements, specifically percentages of gross revenue, percentages of procedures performed. To me that implies that somewhere in the organization there should be policies, procedures, staffing for enforcement, review and enforcement. Is this agency charged with that or is another agency charged with that?
Ms. [??] [??]: You mean as far as the 75%?
Mr. Ed Hamilton: Yeah.
Ms. [??] [??]: That would be our responsibility.
Mr. Ed Hamilton: Okay, does it just come into review at the time an application is made and there’s no subsequent oversight of those guidelines at a later date? Once again, understand this is the guy who came from Medicare compliance with CMS and OIG looking over his shoulder.
Ms. Sonia Chambers: I think the short answer is that the agency has the authority to audit and enforce that.
Mr. Ed Hamilton: Okay.
Ms. Sonia Chambers: I don’t believe the agency has done any of that to date.
Mr. Ed Hamilton: Okay. Now the only other comment that I would have, beyond the fact that these are wonderful regulations…
Ms. Sonia Chambers: You should have been part of crafting them, Ed.
Mr. Ed Hamilton: There needs to be a clear dividing line. I envy the people who set that line and obviously things, over time, become a little bit fluid because of development and technology and what happens with the cost of technology as it gets depreciated in one place and flows back out into the market, which is one of the concerns that we have as it relates to diagnostic testing and equipment, your CTs, MRIs, that kind of stuff. That stuff is sitting out there a lot of times for a song and a dance half used. You can pick it up, move it into a physician’s practice, and start producing revenue regardless of the quality of the work, so to speak. So that’s one of the concerns that we have organizationally is that two million dollars is a guideline, but also we’re talking about specific types of equipment that, from a quality standpoint, we have questions about. Obviously we’ve had people who have avoided the West Virginia regulations by going to Ohio, across the river, and setting up shop over there, so that’s one of the comments that we would make. The other comment is anytime these situations take place they pull revenue from the hospital setting and we’re also specifically interested in making sure the hospital operations are self-supporting, because when they’re not self-supporting that results in higher rates and we know where that goes, especially in the environment that we’re looking at now where it looks like the Feds are once again cutting back on their funding. There’s obligations that are out there that facilities need to meet and sometimes get shifted over to the private payers and of course the private payers shift it over to the employers and the employers shift it over to the employees, so it all goes down the line. That would be the only comment that we would make at this point.
Ms. Sonia Chambers: So can I ask you specifics? Do you support having the exemption, keeping the exemption in place or not, or do you have an opinion?
Mr. Ed Hamilton: Well yes we support the exemption, but we also support a dividing line, an exemption within reason, boundaries on the exemption.
Ms. Raymona Kinneberg: Can I ask the question differently, which is do you support the regulations that outline what is exempt and what’s not exempt?
Mr. Ed Hamilton: Fine set of regulations.
Ms. Sonia Chambers: Mr. Thomas.
Mr. Jim Thomas: Well yes, this is Jim Thomas. I’m here on behalf of the West Virginia Hospital Association today and our position is that the West Virginia Hospital Association supports the continued reviewability of those health services offered by health professionals as they are currently enumerated in the legislative rule in Title 65, Series 17. We are not here to advocate any change overall to that series of regulations. Yet.
Ms. [??] [??]: See Amy, you didn’t believe me that this did not come from them. We really were just kind of interested in getting some input, really.
Ms. Sonia Chambers: Mr. Gray, just happy to be here?
Mr. Bob Gray: I am happy to be here. Back to Ed’s question on 21b and c, on the high end imaging equipment, when the private practice gets an exemption is there a reporting requirement that goes with that? You said that the Authority has the authority…you have the authority to look at the 75/25 split on referrals, but there’s not a reporting requirement that goes along with that, so it’s self-policing?
Ms. [??] [??]: We have the right to request that information. There’s just not a process enumerated in the rule.
Mr. Bob Gray: With the exemption is there financial disclosure?
Ms. [??] [??]: No.
Mr. Bob Gray: Is there reg review?
Ms. [??] [??]: No.
Mr. Bob Gray: Okay and are you going to be taking written comments?
Ms. Sonia Chambers: Yes. Mr. Gregory are you adding anything?
Mr. Tony Gregory: No, I think Jim articulated our position very well.
Ms. Sonia Chambers: You’re just happy to be here aren’t you Martha? Okay. Phil?
Mr. Phil Wright: Hi, how are you?!! I’m happy not to be there. Where I’m at it’s snowing.
Ms. Sonia Chambers: You’ve been really quiet.
Mr. Phil Wright: Yeah, I know. I can’t stand it. Hey, a couple of things. You know we’re having a real difficult time getting doctors in West Virginia. Does anybody disagree with that? Thank you. Every time I turn around we’re short of neurosurgeons, we’re short of surgeons, we’re short of urologists, it goes down a list. Do you think there’s any reason that the regulations may be causing that? I don’t know, but for some reason we’re having a tremendously difficult time in West Virginia getting doctors.
Ms. Sonia Chambers: I am sure that Evan Jenkins would like to comment on that.
Mr. Phil Wright: I know it’s malpractice and some of that’s fixed, but we still have defensive medicine being practiced in certain pockets of the state where there’s a large plaintiff attorneys set up. I know that’s continuing, but beyond that we just have doctors aging into retirement with no replacement coming in and it’s very difficult, I’m told, to recruit physicians, so I don’t know how these affect that. I don’t know if they do, but I have another question. Once you get beyond two million, say in 1999 you’re required to do a CON. Once you do that CON, is there any requirement or rule or regulation that requires additional if you go beyond that?
Ms. Sonia Chambers: Well it would depend exactly on the issue and I’m going to try this and I’m looking at my lawyers who may jump in. Phil, are you asking for instance, and I think this issue has come up in some of our prior discussions, let’s say that you were exempt because prior to the rule being changed and CT being added to the list you got a CT and now you want to upgrade it, for some reason, to the hundred and…whatever the next…it’s the generation after the 64 slicer, which is over two million dollars.
Mr. Phil Wright: Or even additional services. Once you’re past the two million what happens? You just want to add other things because you’re beyond the two million.
Ms. Sonia Chambers: If you’ve already done…if you already have the service then it’s not reviewable unless it’s over two million dollars. Do you understand?
Mr. Phil Wright: Yeah, but if you give a CON to a physician group in a remote area, once they have that CON can they add at will…
Ms. Marianne Kapinos: You’re going to trigger the two million dollars.
Ms. Sonia Chambers: They could add services as long as it doesn’t…they could add equipment as long as it’s one not specifically listed unless they already have that service like CT or unless it’s…let’s say they came in for a CT machine and they got a CT machine, they came in and it was reviewable. Now let’s say they want to add another CT machine. As long as that second one is not over two million dollars, the addition of the second one would not be reviewable.
Ms. Marianne Kapinos: Right. Are you talking, too, about just a series of expenditures that incrementally would add up?
Mr. Phil Wright: Yes.
Ms. Marianne Kapinos: Okay, that’s what I thought. There’s a two year period. I mean even if one expenditure is not two million dollars, but if there’s a series of expenditures within a two year period that are related and they exceed that two million dollar cap, then that would be subject to review.
Ms. Cindy Dellinger: I didn’t explain all that. I didn’t want to go to like the…
Mr. Phil Wright: Okay. I didn’t hear it anyway.
Ms. Cindy Dellinger: When I explained the two million dollars, there’s a whole thing that triggers our two million dollar cap. I didn’t want to bore everyone with [unintelligible], but if you want me to the two million dollars includes the cost, the study, surveys, design, plan, working drawings, specifications, other activities, things like that and if you buy a piece of equipment that’s for less than the fair market value, that piece of equipment we consider the fair market value of the piece of equipment and like Marianne said, if you have a piece of equipment and you string it out over two years and it’s actually a series of expenditures and we can actually look at a series of expenditures to see if that triggers our cap if that’s your question.
Ms. Sonia Chambers: There is a difference between what goes into the two million dollars for imaging centers that are physician office practices and what would be the count in the two million for a hospital and an imaging service.
Ms. Cindy Dellinger: Right. There’s a difference for this and an actual hospital would be. This doesn’t include the build out for the physical plant, which is different. It’s just that the hospital would include the actual build out for the facility. This doesn’t include the build out for the actual physical plant, which is different.
Mr. Phil Wright: Well Sonia, okay I think I stirred a nest I didn’t want to, but anyway I was trying to understand it. I think I do now. The one thing that health plan has always done is try to support the hospitals and try to keep the services within the hospital. When these groups come in…we’ve had radiation imaging companies come in, try to put up shop across the river in Ohio or other states, and we just don’t go for that. We try to keep the services within the hospitals in West Virginia, so I’m for the regulation, but I’m also, when it comes to the physician, I’m very concerned that we’re having difficulty recruiting physicians. We have had to transfer so many patients out of West Virginia because of the lack of physician availability or don’t have the specialty needed. It goes on every day and I don’t know what we have to do, but there’s an aging populations of physicians that we’re going to have to replace and it’s just not happening as fast and as well as we’d like. There just seems to be a lack there and then on the other side, there’s also the physician pockets in West Virginia that demand certain rates that are beyond reason and that becomes very challenging, also, so I’m not sure what the answer is and maybe it’s not in this subject, but we have a tremendous problem in West Virginia, in my mind, recruiting physicians and especially the specialty area. I don’t know what the stats are from the medical schools turning out physicians, how many are staying in West Virginia, but it’s my understanding that the numbers are very low when it comes to specialists and I think we have to do something to reverse that. We have to get some of these specialties to stay in West Virginia for a period of time or something and I’m not sure the regulations have anything to do with that, but we have a major problem here and I don’t know if this is even something that can help address it. Is there anyone that disagrees with that? Please say something.
Mr. Bob Gray: I disagree with you. I think the problem may be more geographic than it is recruitment. One of the hats I wear is physician recruiter for the Thomas Health System and I’ve recruited 48 doctors to Charleston in the last two years.
Mr. Phil Wright: I think Charleston is a little bit out of the loop. That’s right in the heart of the state capitol. I don’t think you see near the court activity that we do in other parts of the state.
Mr. Bob Gray: That’s why I think it’s a geographic problem.
Mr. Phil Wright: I think it is, too. I agree with that.
Ms. [??] [??]: Court activity, you mean lawsuits?
Mr. Phil Wright: Yes.
Ms. [??] [??]: I used to practice law in Wheeling. It’s a totally different litigation environment in terms of malpractice lawsuits than it is in Charleston.
Mr. Phil Wright: Um hmm.
Mr. Evan Jenkins: Phil, you asked the question does anybody disagree and you asked your first question of is it an impact and the answer, I think, is yes it is. Now to what degree? Is it a small factor or a large factor? That’s kind of the challenge and I think this is not simply speculative as to it being a factor when you look at the, I guess, so called the converse of this is while you characterize the question as is it an impediment to coming into the state, the converse of that is we know without question that the regulatory rules have facilitated or been impetus to cause practices, physicians to leave the state, so if it’s pushing them out I would think you would have to assume that there are those who aren’t coming as a result. I applaud the Health Care Authority for, I think, commissioning the study. At WVU we’re looking forward to the analysis of what is the financial impact of causing health care services to be moved across the river, just as you’ve seen in the northern panhandle. I’m hoping that because so much of what we’ve dealt with theoretically is this public policy balancing test. Hospitals say these are important revenue sources that offset uncompensated care in the ER. Doctors say it’s limiting their ability to engage in the independent practice of medicine without the regulatory oversight, so all of this…this is regulation. This is limiting activity all for a proffered reason that people have varying degrees of agreement on whether or not it’s carrying out the purpose for which it was designed, so to answer your question do I think it is impacting the ability to recruit to West Virginia, the answer is yes and we could all either disagree with that or we could have a substantive discussion about what is the degree that it is having, but I don’t see how, in a highly regulated environment where we are one of the supposed five most restrictive states in the country, to suggest that a physician seeking to place a practice isn’t doing the due diligence to analyze what is the environment within which I’m applying and this regulatory environment is a contributing factor I would think, because we certainly have seen people go the other way as a result.
Mr. Phil Wright: Yes, I agree.
Ms. Sonia Chambers: All right. Angela, Nancy.
Ms. Angela Swagger: We don’t have anything to add.
Ms. Sonia Chambers: Okay, Dave Jarrett.
Mr. David Jarrett: Nothing to add.
Ms. Sonia Chambers: Bob Coffield.
Mr. Bob Coffield: I’m just here to listen.
Ms. Sonia Chambers: Anybody from BMS.
Ms. Pat Woods: We don’t have anything else, thanks.
Ms. Sonia Chambers: I’m just curious, from BMS, who’s…
Ms. Pat Woods: This is Pat Woods and Stacy Hanshaw.
Ms. Sonia Chambers: Okay, thanks Pat. All right. Anybody or anything else? If not, I appreciate everybody’s time and attention. Let me remind you that we would be happy to get written comments. We would ask that you provide those within 30 days. We have promised to synthesize all the results of these meetings and pass them along to the legislature, so if you would please get those to us within 30 days. If you could send those to Dayle Stepp, we would greatly appreciate it and copies of this information and the transcripts, when they’re available, will be available on our website. All right, thank you very much.
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