THURSDAY, JULY 25, 2013: SUBMITTED BY BOARD MEMBER W MICHAEL TROUT for discussion, to be distributed either as part of BOD Agenda

, or forwarded under separate cover to Board members simultaneously with Agenda/Minutes packet for July meeting. REITERATING MY COMMENTS FROM LAST MONTH … I think it's imperative that we allocate more time during our meetings for general BOD discussions. QUALITY COMMITTEE MEETINGS :: With time to reflect on Mr Irrizary's characterization of the importance of the Quality Committee meetings, I am more convinced that as many members of the BOD should be participanting in those meetings as possible, especially in our first year of operation. DISCUSSION: Shall the Board reconsider the timing of those meetings to coincide with the day of our regular BOD meetings, either immediately prior, or after the regularly scheduled BOD meetings? Is there a motion? NEW GRANT MONIES :: DISCUSSION: Repeating Dr Michael Dennis' call to devote 10% of resources to education about diet and exercise to the community, shall the BOD allocate 10% of the new grant monies to programming of that activity? (About $50,000?). Is there a motion? TAKING OUR MESSAGE(S) TO THE STREET :: Call this a personal wish/suggestion item. I would like the BOD to consider the value of an agile technology for public communication – namely, the placement of large (50” to 70”) screen electronic message boards (hi def TV sets) on or near our clinic campuses for the purpose of educating the public passersby of the new and comprehensive Primary Care options available through our clinics? These would probably require construction of vandal proof enclosures and wired or wireless connection to our administrative offices. In terms of rapid message deployment, this might prove to be of great value in first line communication to the public. (Briefly discussed with Mr Irizzary and Mr Rodriguez.) DISCUSSION, DNA BREAST CANCER SCREENING (BRCA 1 & 2) (and others) :: Maybe a year or more ago, there was an article in the medical literature about a great breakthrough in genome sequencing that claimed a thousandfold reduction in cost. At the time, the report stated that the current cost was about $14,000. If I'm not mistaken, the way they achieved this dramatic breakthrough was through the development of systems that could sequence 1000 samples at a time, rather than just one. Doing the math, a thousandfold cut in cost should have brought the cost down to $14. So why is it that recently, when Angelina Jolie went public about her choice to undergo a double mastectomy -- she expressed her frustration that the (DNA) test that she underwent to screen for the BRCA (1) & (2) cost $3000, a sum that many (maybe most) could not afford? Are DNA testing firms charging outrageous amounts for a test that could be a significant and important screening tool for women? Are there some (much) lower cost alternatives available through Public Health partnerships? Shall the Board investigate options to benefit at risk women and men in our client population? (Men who carry the gene have elevated risk for prostate cancer.) Shall the board cause the implementation of a protocol for volume, relatively low cost DNA screening of members of our client population who are medically indicated for such screening? Some Gov/Health Info :: http://www.cancer.gov/cancertopics/factsheet/Risk/BRCA http://genome.gov Some 'Commercial Labs offering BRCA testing :: http://ambrygen.com/tests http://breastcenter.com/BRCATesting Priority Areas for National Action :: Transforming Health Care Quality http://www.ahrq.gov/professionals/quality-patient-safety/patient-safetyresources/resources/iompriorities.html

EXCERPT (INTRODUCTION) :: “This AHRQ-funded report from the Institute of Medicine (IOM) documents disturbing shortfalls in the quality of health care in the United States. In 2001, an IOM report recommended the systematic identification of priority areas for quality improvement. This new IOM report outlines guiding principles, criteria, and a list of 20 priority areas for improvement.

FYI :: MEANINGFUL USE :: WHAT IS MEANINGFUL USE (AS ASSOCIATED WITH ELECTRONIC HEALTH RECORDS (EHR's) :: EXCERPT :: “Electronic health records can provide many benefits for providers and their patients, but the benefits depend on how they're used. Meaningful use is the set of standards defined by the Centers for Medicare & Medicaid Services (CMS) Incentive Programs that governs the use of electronic health records and allows eligible providers and hospitals to earn incentive payments by meeting specific criteria. For details about the incentive programs, visit the CMS website. The goal of meaningful use is to promote the spread of electronic health records to improve health care in the United States. http://www.healthit.gov/policy-researchers-implementers/meaningful-use

The Office of the National Coordinator for Health IT along with the Center for Medicare and Medicaid Services have compiled a list of Electronic Health Record products used for the attestation of Meaningful Use under the CMS Medicare and Medicaid EHR Incentive Program. The file containing this data is in a csv format and is updated monthly. In addition, a data dictionary is provided that describes the variables available in the dataset. Finally, a factsheet is offered to explain how the data is generated and how to best use it. http://www.healthit.gov/sites/default/files/mu_report.xlsx http://www.healthit.gov/sites/default/files/pdf/HealthDataGov_MU_Attest_Fact_Sheet.pdf http://www.healthit.gov/sites/default/files/pdf/healthdatagov_mu_attest_data_dictionary.pdf

FoundCARE is an FQHC Lookalike operating within our service area. See their website at http://foundcare.org. See their Facebook page at https://www.facebook.com/FoundCare

In addition there are other FQHC's and look-alikes operating within our service area – how can we partner with these other service organizations to better serve client communities?

Fierce Healthcare Newsletter: Community health centers face ACA dilemma Programs expect millions of new patients but not enough funding to keep them http://www.fiercehealthcare.com/story/community-health-centers-face-aca-dilemma/2013-0716?utm_medium=nl&utm_source=internal

REGARDING OUR CONTINUING CONVERSATION ABOUT TRANSPARENCY IN CLINIC PRICING :: WOULD LIKE TO REFER THE BOARD TO THE FOLLOWING INVESTIGATIVE ARTICLE BY THE WASHINGTON POST :: How a secretive panel uses data that distorts doctors’ pay :: http://www.washingtonpost.com/business/economy/how-a-secretive-panel-uses-data-thatdistorts-doctors-pay/2013/07/20/ee134e3a-eda8-11e2-9008-61e94a7ea20d_story.html

A PHYSICIAN that we pay $160,000 per year averages approximately $80 per hour, not including ancillary costs. Depending on the average patient load, if the physician is seeing 4 patients an hour, there is a base cost of $20 per appointment. If the physician is seeing 6 patients in an hour, the cost reduces to $13.33, and 8 patients per hour to $10.

How do we differentiate pricing for a patient appointment that is attended by a physician, versus an appointment that is attended by an ARNP? An ARNP compensated at $65,000 per year averages approximately $32.50 per hour, not including ancillary costs. If the ARNP is attending 4 patients per hour, there is an approximate base cost of $8.12 per appointment. If we increase the patient load to 6 per hour, the relative cost per appointment reduces to $5.41, and if we increase the patient load to 8 per hour, the cost reduces to $4.06 per patient.

Hospital charges, Medicare reimbursement out of whack :: Study finds investor-owned, urban facilities charge the most :: “Although Muhlestein expected some variability in charge-toreimbursement ratios among hospitals, he said he was surprised by the degree. A small amount of hospitals (35 out of 3,337) actually have an average Medicare charge that is less than what they were actually reimbursed. But others, he said, bill, on average, as much as 16 times what they receive in Medicare reimbursement.” http://www.fiercehealthfinance.com/story/hospital-charges-medicare-reimbursement-outwhack/2013-07-188

MEDSCAPE 2012 PHYSICIAN COMPENSATION REPORT :: http://www.medscape.com/features/slideshow/compensation/2013/public

REGARDING PHYSICIAN RECRUITING, I wonder if the BOD should take up the topic of starting compensation (salaries) for physicians, and also whether or not it is appropriate to recruit a husband and wife team, as we almost did with the Paredes. As an organization, I don't know if HCD has any particular rules that might apply to hiring of family members. Are there situations that it might be problematic? Shall the BOD discuss the possible adoption of rules regarding (nepotism)?

There are approximately 850 family practitioners in PBC, according to at least one resource. In addition, there are specialists in the 24 major specialties with vibrant private practices. Can we discuss the possibility of developing parameters for a program of recruiting highly competent talent in ways that don't necessarily pull private practitioners away from their practices – for instance – recruiting through the PBC medical associations for physicians who might be interested and willing to participate in our public health system on a limited part-time basis – for instance on Wednesdays, Fridays, and Saturdays once a year, twice a year, quarterly, monthly, or weekly basis. If we were successful in meeting client demand this way with primary physicians, we could look in the future to allow specialists into the mix, giving them the opportunity to contribute, without disrupting their private practices. We might find that some physicians might even wish to donate time on a limited basis.

RECRUITING VOLUNTEERS NOT OPTIONAL :: OBAMA ORDERS AGENCIES TO RECRUIT http://www.govexec.com/management/2013/07/obama-orders-agencies-recruitvolunteers/67121/?oref=govexec_today_nl

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