HEAL NY PHASE 6 PRIMARY CARE INFRASTRUCTURE RFA NO. 0712201140 Governor Nelson A. Rockefeller Empire State Plaza Conference Room 3 Albany, New York February 4, 2008 10:10 a.m - 11:50 a.m. APPEARANCES: Christopher Delker James W. Clyne, Jr. Neil Benjamin Robert Schmidt Larry Volk Charles Abel Tracy Raleigh Jay Laudato ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 2 1 MR. DELKER: Good morning. Thank 2 you for coming, especially those of you who 3 were up late celebrating the Super Bowl last 4 night. Bob and I were speculating Friday night 5 that this might be a very docile audience from 6 too much food and drink the night before, but 7 you look pretty lively. 8 I would just like to give a preview of 9 what we're going to do here. Everyone should 10 have gotten one of these agendas as you came 11 in. And let me just walk you through the main 12 parts of it. 13 Jim Clyne, Director of Office of Health 14 Systems Management, and Neil Benjamin from the 15 Division of Health Facility Planning, they're 16 going to open this briefly by talking about 17 what we expect out of this initiative but, more 18 importantly, how it links with the 19 restructuring that has been going on in the 20 health care system for about three years now, 21 starting with the Berger Commission and then 22 with several iterations of HEAL. 23 After that we're going to talk to you 24 about eligible costs, what you can and cannot 25 ask for, what this grant will and will not pay ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 3 1 for. 2 Then we're going to describe the basis 3 of the awards, the main factors that we'll 4 consider in giving the awards and the scoring 5 mechanism in general terms and how we're going 6 to be weighing various factors in consideration 7 of the applications. 8 Then we're going to walk through the 9 application process. There are two parts to 10 the application -- a technical and financial, 11 as you've probably noticed. And it's important 12 to address those things in their own 13 distinctive parts, so we'll walk you through 14 that just to make sure you understand 15 everything. 16 And then we're going to talk about 17 submission of applications -- how many copies, 18 when, to whom, what format, what medium and 19 everything. 20 Then we get to the questions and 21 answers, and that's the main purpose of this 22 session. You want to know how to go about 23 developing an RGA, what we may or may not 24 consider, and so that's going to be the bulk of 25 this. So we ask that you hold your questions ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 4 1 until the end. We want to go through this, 2 what I've just described fairly quickly. So 3 the bulk of these two hours is going to be your 4 opportunity to ask questions. 5 And I have to say a couple of other 6 things about this being a competitive 7 procurement process. Here we go. Many of you 8 are familiar with grants under the various 9 formats and under various auspices like 10 categorical grants or grants and aid and so on. 11 These are a little different. These are 12 competitive procurement grants, and they're 13 governed by the State Finance Law. And what 14 that means is that any information -- one of 15 the things it means is that any information 16 that is imparted on these grants has to be 17 imparted or available to everyone at the same 18 time, so that means in this forum or in the 19 question and answer forum on the web. So that 20 will keep you from asking us any other 21 questions other than in this forum and in that 22 forum. So what that means in practical terms 23 is you can't come up to us afterwards and ask a 24 follow-up question or anything like that, or I 25 wanted to clarify this or that or something ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 5 1 like that. You know, we like to be sociable. 2 If you want to come up and talk about the Super 3 Bowl or anything, that's fine. But if you talk 4 about anything related to these grants we'll 5 have to be rude and pretend we didn't hear you. 6 This is part of the competitive 7 procurement requirement under the State Finance 8 Law, and it's also the reason we have to score 9 the applications we do, using uniform scoring 10 criteria and other things like that which we'll 11 get to more of later. 12 I think for right now I would just like 13 to introduce the panel. I'm Christopher 14 Delker, Division of Health Facility Planning. 15 MR. SCHMIDT: I'm Bob Schmidt. 16 I'm the Director of the Implementation Team. 17 MR. LAUDATO: I'm Jay Laudato from 18 the Office of Health Insurance Programs. 19 MR. ABEL: Charlie Abel, 20 Department of Health, Health Facility Planning. 21 MR. VOLK: Larry Volk, Dormitory 22 Authority. 23 MR. BENJAMIN: Neil Benjamin with 24 the Division of Office Health Facility 25 Planning. ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 6 1 MR. CLYNE: Jim Clyne, Office of 2 Health Systems Management. 3 MS. RALEIGH: Tracy Raleigh, 4 Dormitory Authority. 5 MR. DELKER: We have some other 6 people with us as resource people. Marybeth 7 Hefner and Cynthia Miner are here from the 8 Office of Fiscal Management, Bureau of Accounts 9 Management, and they keep us on the straight 10 and narrow as to what gets to the Comptroller's 11 Office. So they're very important in the 12 development of the RGA and in the contracting 13 process after you receive an award. So we 14 listen very carefully to whatever they tell us. 15 We also have other staff from HEAL who will be 16 introduced later. And I see scattered 17 throughout this room some of our colleagues 18 that you probably know from the Primary Care 19 Initiative and the CHCCDP Program. We're 20 fortunate to have them working on HEAL now as 21 well. They asked that I not identify them, but 22 you know who they are, and they're here in 23 force to listen, and they will be helping out 24 later with the RGAs and the contracts. 25 I'd like to turn it over now to Jim ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 7 1 Clyne, the Director of the Office of Health 2 Systems Management. 3 MR. CLYNE: Good morning. I 4 especially wanted to thank the Patriot fans who 5 maybe are drowning their bitter loss. As a 6 Giant fan, I feel quite energized by last 7 night's game and by this RGA. I'm serious. A 8 hundred millions dollars for primary care 9 development is fairly substantial, and it 10 supports the Governor's commitment to reform of 11 healthcare, moving away from 12 institutional-based programs and an attempt to 13 bring services into the community where they 14 belong. 15 This was a product that was developed 16 by the Office of Health Systems Management with 17 the Office of Health Insurance Programs, so Jay 18 Laudato is going to say a few words after me 19 and with our partners in the whole HEAL 20 process, DASNY. 21 Opening up HEAL to the 22 non-institutional providers, primary care 23 providers, will help implement the Berger 24 Commission's recommendation for strengthening 25 the primary care network throughout the State. ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 8 1 It also occurs at a time when we're 2 restructuring Medicaid payments to provide for 3 the greater support of primary and ambulatory 4 care. These two are working together, both 5 this one-time investment in creating primary 6 care and the budget proposals that Jay is just 7 going to mention on restructuring the payment 8 systems, all headed towards trying to identify 9 community needs and putting patients first. 10 It was difficult to put together an RGA 11 that met the diverse needs of all of New York's 12 communities and the individuals residing 13 therein. In some areas of the State, in rural 14 areas, better access to primary care include 15 just setting up a new clinic. This RGA can 16 support that. But better access to primary 17 care doesn't just mean more clinics, and in 18 many cases we definitely do not want to see 19 more clinics in the areas where we already see 20 plenty of them. What it could mean there is 21 making the existing clinics better, more 22 efficient and able to serve more people with 23 special populations, and this RGA can support 24 that. It can also mean connecting people to 25 the existing clinics that are out there who ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 9 1 face barriers to accessing care, and we think 2 this RGA can do that also. 3 So we encourage you to be innovative. 4 We don't think that we've thought of all of the 5 good ideas for primary development and how they 6 work. We're really excited and interested to 7 see what the field comes up with. Be 8 resourceful in applying for the funds. As 9 Chris said, this is a closed RGA. We'll be 10 able to talk to you in April. Thank you. 11 Jay Laudato is going to say a few 12 words. 13 MR. LAUDATO: Thank you, Jim. On 14 behalf of Deborah Bachrach, the Deputy 15 Commissioner for the Office of Health Insurance 16 Programs, we're very grateful to be working 17 with the Office of Health Systems Management on 18 this extremely important funding opportunity 19 for the health care providers of New York 20 State. 21 Deborah asked that I speak just very 22 briefly but very specifically about the budget 23 proposals that are coming forward this year. 24 Primary care expansion and improvement is the 25 center piece of the Medicaid program's policy ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 10 1 and fiscal agenda. In this year's budget there 2 are significant ambulatory care reimbursement 3 reforms primarily geared to reimbursing 4 appropriately for the time and resources needed 5 to deliver quality primary care and other 6 outpatient services. Specifically, the new 7 methodology will remove any disincentives from 8 treating medically complex patients by fully 9 reimbursing for all of the services provided 10 within a patient visit. 11 Equally, the Department recognizes the 12 vital importance of patient education 13 especially as it relates to chronic diseases 14 and adherence to treatment regimens. 15 Accordingly, within the budget there are 16 proposed initiatives that will reimburse for 17 the education of asthmatics and diabetics, as 18 well as demonstration projects, performances 19 delivered medication therapy management. 20 Further, to improve access there is 21 funding increases intended for the provision of 22 evening and weekend hours. These budget 23 initiatives are very significant and important, 24 and we want to make you aware of them as you 25 understand this funding opportunity. Thanks. ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 11 1 MR. DELKER: One thing I should 2 say in addition about the provisions of 3 competitive procurement, I didn't mention 4 earlier, is that everything I say here will be 5 available on a transcript that will be posted 6 on the web probably ten days to two weeks from 7 now. 8 Also, anything we say here, we reserve 9 the right to consider preliminary. We're 10 confident that we are able to answer most of 11 your questions fully and factually, but 12 occasionally, if there is a need to correct or 13 clarify something following advice from counsel 14 or other considerations, if we do issue any 15 clarifications or corrections about anything 16 said here, we will post that on the web at the 17 time we post the transcript. So just keep your 18 eye on the web over the next couple of weeks, 19 the Department of Health website, and check the 20 transcript and any clarifications we might 21 issue at that time. 22 The next speaker is Neil Benjamin. 23 MR. BENJAMIN: Thank you, Chris. 24 I just want to talk a little bit about the 25 purposes and a little bit of an overview of ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 12 1 this particular RGA. Because so many changes 2 have occurred to the way that the Department 3 views applications for primary-care-type 4 services over the past five or six years, our 5 main mechanism for that has been a Certificate 6 of Need process, and to the extent that 7 whatever your proposal is, SHRPC, a CON 8 threshold, that will still have to be applied. 9 But regardless, we've learned a lot over these 10 past five or six years about just what really 11 constitutes a truly worthwhile proposal for 12 primary care access, whether it be for 13 additional resources or for better management 14 of what's out there so that the goal of 15 patient-centered care continues to be pursued 16 and hopefully implemented. 17 Now, patient-centered care is something 18 that, as Jim mentioned, is a major goal of the 19 Governor and Commissioner Daines. And what it 20 really means to us in planning is a fundamental 21 shift from looking at an application, whether 22 it be a HEAL application, a CON application, or 23 whatever, looking at it from the perspective of 24 the institution and what does it mean to the 25 institution's ability to deliver services. ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 13 1 Well, that's still important. One of the most 2 important things we're now going to be looking 3 for is a demonstration of knowledge by 4 providers of the characteristics of the 5 patients that they serve and maybe some of the 6 patients that they don't serve but live in 7 their communities and could certainly benefit 8 by, you know, furtherance of their mission and 9 their services. 10 One of the things that we've really 11 embarked upon again in the CON over the last 12 five years was a very -- becoming much more 13 strict on the issue of public need for these 14 types of services. And we've -- you know, we 15 think that because of those policies we've 16 diminished quite a bit the incentives for 17 certain types of services from the financial 18 standpoint and kind of moved it over to the 19 clinical and inpatient care. 20 Now, important to all of this, though, 21 and following up on what Jay said, is what is 22 really -- at the end of the day, what is really 23 the goal of all of this in terms of access to 24 services and the cost of health care? And 25 cost, I mean everything, particularly the ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 14 1 Medicaid Program, as so many of you may serve 2 probably quite a few beneficiaries. So if you 3 think about it, and the way we've been talking 4 a lot is, you know, at the end of the day 5 what's the goal? Well, the goal I think is to 6 keep people healthier, treat them earlier, 7 intervene earlier in their health care needs so 8 that maybe not tomorrow, maybe not next week, 9 maybe not even next year, but in the reasonable 10 future those patients will remain healthier and 11 therefore not require more costly interventions 12 and that, you know, any financial incentive 13 that there may be for simply generating 14 revenues versus actually treating patients so 15 that they stay healthier are removed. 16 So this RGA really talks about two 17 things; one is, in areas where it's needed, 18 expansion of primary-care-type services. And 19 then the second, equally as important, if not 20 more important, is better management of the 21 services that you do provide and reaching more 22 of the population than you may -- 23 We're all excited because not only have 24 we tried to change our focus in planning over 25 the past five years with these types of ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 15 1 applications but the databases that are now 2 available to us are so much more sophisticated, 3 both externally as well as internally. Our 4 close work with the Office of Health Insurance 5 Programs, etcetera, as well as some of the work 6 that we're doing, trying to identify and make a 7 fundamental shift in planning. And what I mean 8 by that is not simply getting applications in, 9 whatever they maybe, and say, okay, here's our 10 little secret formula, and then we're going to 11 make a decision, and here is what it is and 12 live with it. We don't want to do that 13 anymore. We want to make sure that what we 14 have available to us, in terms of the health 15 status indicators of the people in your 16 community, is also available to you. And some 17 of you may have heard me speak in other forums 18 about this exciting project that we're very 19 close to rolling out, and it's what we call a 20 "PQI navigator." And it's going to be 21 something that will be web-based on the 22 Department's website where anyone who has 23 access to the internet will be able to go in 24 and take a look at the incidence of preventable 25 hospitalizations as measured by the federal ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 16 1 PQI, Prevention Quality Indicators. We've been 2 able to marry that to the SPARCs data and also 3 by zip code. You'll be able to add zip codes, 4 subtract zip codes. There will be many, many 5 drop-down boxes that will give you a lot of 6 additional information. It's a tool that we 7 think is very important for all of you to be 8 able to begin to move in tandem with us in this 9 approach towards your communities. We 10 contracted out some assistance on this. The 11 product is back, and it's in a very intense 12 testing mode right now, and we're hopeful that 13 will be available to everybody as you move 14 through this application process. So that and 15 other data that we have available, we're 16 excited about aligning not only with all of 17 us -- with the Dormitory Authority, OHIP, and 18 us, and OHSM -- but also with you, the 19 providers, so that collectively we can move 20 forward with this, you know, exciting 21 initiative. Like Jim said, a hundred million 22 dollars for primary care, you know, even in 23 today's economy that's probably close to what 24 you call real money. So we're excited, and we 25 have everyone here who can certainly expand ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 17 1 upon the technicalities of it as well as answer 2 questions later. 3 So thanks for the opportunity to 4 address you, and we'll look forward to talking 5 later. 6 MR. DELKER: Okay, just to kind of 7 reemphasize what Neil said and to reiterate the 8 purposes of this request for grant 9 applications, it does complement the downsizing 10 supported by earlier efforts of the Commission 11 and earlier HEAL New York funding and to better 12 align resources with needs, as Jim said. So 13 even though we've been giving out HEAL money 14 for about a year and a half now, and you may 15 feel this has been a long time coming, I think 16 this is the logical next step, and the timing 17 is just right. The initial down-sizings have 18 been completed. In a lot of communities, that 19 means less inappropriate inpatient care and 20 more need for primary and preventative care. 21 So we see this as the right timing, and we look 22 to you as a resource to help all of that 23 happen. And I think the third bullet there is 24 the most important. The real purpose of this 25 whole effort is to improve health status of ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 18 1 people, to get the right services to people in 2 primary care and prevention. And if you 3 emphasize that in your applications that 4 certainly is going to serve you well. 5 We need to clarify a little bit about 6 eligible applicants. In every HEAL iteration 7 we've done we've gotten some applicants who are 8 not eligible despite our best efforts to 9 describe what an eligible applicant is. An 10 established diagnostic and treatment center or 11 clinic under Article 28 of the Public Health 12 Law -- probably most of you are affiliated with 13 those organizations -- they are eligible to 14 apply; so are hospitals to operate extension 15 clinics or expand or enhance outpatient 16 departments for the purposes of providing 17 primary care, and also any entity that feels 18 that they can meet those requirements, the 19 Certificate of Need requirements for a D&T 20 center and the operational ones as set forth in 21 Part 710 for CON and 750 and the succeeding 22 parts in the 750 series, depending on the type 23 of operation. If you feel you can meet those 24 and will use capital for this grant to help 25 establish a claim, you are eligible. ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 19 1 In some ways it's easier to say who is 2 not eligible. Specialty care is not a primary 3 care. Care by non-medical licensed 4 practitioners, such as physical therapists and 5 so on, is not primary care for these purposes. 6 There are as many ways to define primary care 7 as there are people who provide it and advocate 8 for it, and certainly I'm sure all of you could 9 come forth with a very, probably, precise and 10 persuasive definition. This is the one we 11 worked on in the Department, kind of a 12 consensus among us. But this is what we mean, 13 and this is what your applications should 14 reflect, this kind of activity. 15 Now, Article 28 has some provisions in 16 it. This is statutory language. Article 28 of 17 the Public Health Law is the law that 18 authorizes hospitals, nursing homes, clinics 19 and so on, D&T centers, but the statutory 20 language defining an Article 28 facility is a 21 facility or institution engaged principally in 22 providing services by or under the supervision 23 of a physician or a dentist. And that word 24 "principally" is key. Generally, we use that. 25 The majority of visits have to be for services ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 20 1 by or under the supervision of a physician or a 2 dentist. So this is not to say that 3 non-medical services are not part of primary 4 care. Certainly, they are -- mental health 5 services, physical therapy, and so on -- but 6 it's the proportions that are important here. 7 The character of your organization has to fit 8 this Article 28 definition if you want to be 9 eligible for this. And just to emphasize, 10 dental clinics are eligible to apply here 11 because they do fit this definition. So a 12 single-purpose application for dental services 13 would be eligible for consideration under this 14 application. 15 Now that we've talked about eligible 16 applicants we're going to go to eligible 17 activities and costs. And for that we're going 18 to kind of do a tag team or something here, but 19 the lead is going to be taken by Bob Schmidt, 20 who is Director of the HEAL Implementation 21 Unit. And so Bob is here to my immediate 22 right. As Director of HEAL, he's the one who 23 is really out there on all of this, and he's 24 the voice on the other end of the phone or the 25 man behind the e-mails. If we make mistakes, ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 21 1 we blame him, you know, so -- he does a lot for 2 us. And so he's going to start us through this 3 next section. 4 MR. SCHMIDT: Thanks for that 5 introduction. At the HEAL unit we're 6 responsible for the procurement process and 7 then the contracting process with awardees, for 8 vouchering and project monitoring work with our 9 colleagues in the back who wanted to be 10 nameless, but as far as the direct activities 11 of HEAL, I would like to take a moment to 12 introduce a couple of the HEAL team members. 13 Janice Dee and Joe LeDuc. And during the 14 question and answer period, they will be 15 working the room. They'll each have a 16 microphone, and when one has a person and is 17 asking a question, the other person will be 18 looking for the next question. So they will 19 keep the ball rolling when this is finished. 20 Let's see, let's go into eligible 21 activities. Thank you. Section 1.3.3 in your 22 RGA lists all of the eligible costs, without 23 going into the full list. I mean the important 24 thing to remember, this is a capital program, 25 so we're looking at fund capital costs. Other ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 22 1 costs are -- some of the costs are allowable. 2 We should check the RGA, but think of this as a 3 capital cost program. 4 When you look at the example of support 5 services, some areas, like staff training and 6 system changes and translation, are 7 reimbursable, but it's important to keep in 8 mind that we're not covering administrative 9 costs. We're not covering back-room 10 operations. That's pretty clear in the RGA, so 11 this is not something that is designed for 12 that. 13 Okay, all right, basis of awards. I'm 14 going to talk a little bit about how awards are 15 going to be made. This slide is basically 16 referring to the two primary areas of your 17 application; one is a technical section, which 18 is going to talk about improving access to 19 primary care which all of the speakers have 20 touched upon. And in the second section is the 21 financial section which deals with reasonable 22 cost effective and financially feasible 23 projects. We'll get into that a little bit 24 more as we go through this. 25 How awards will be made, there are two ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 23 1 categories. Category one is the small projects 2 category, so that's for applications that have 3 a request that is no larger than $500,000. 4 Those projects will be awarded first, and the 5 maximum amount will be $20 million for small 6 projects. 7 The next category is regional projects, 8 and the RGA refers to a regional breakout of 9 award dollars that are allocated by Berger 10 Commission regions, and they're basically based 11 on census track data. They've been using 12 previous iterations of HEAL, so most are 13 accustomed to that breakout. 14 I just want to mention too that a 15 maximum amount for hospitals will be $20 16 million. Basically, it's termed "twenty 17 percent of the award pool," which means that 18 there is a lot of money towards smaller primary 19 care facilities, D&Ts, etcetera. 20 Okay, all right, basis of awards. The 21 technical section of the application is going 22 to account for 75 percent of the score, and the 23 financial section is going to account for 25 24 percent. As Chris mentioned, it's derived from 25 uniform scoring criteria. ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 24 1 Just to give you an idea how the 2 applications are processed. They come in, 3 they're numbered. We put together an applicant 4 set, and we start the review process. Stage 5 one review is a review for completeness. We 6 want to make sure that all of the components 7 are there, that everything that was requested 8 has been included. And if that's not the case 9 that could be grounds for disqualification. 10 In stage 2, there is a review process 11 that takes place to make sure that everyone is 12 an eligible applicant so we don't have 13 applicants that don't meet the criteria listed 14 in the RGA for eligible applicant. 15 And then stage 3 is basically the 16 formal, technical program review and the 17 financial review. And then once the scores 18 are tabulated then they're referred to a 19 selection committee and then an awards 20 committee. 21 The RGA lists under 3.2 the scoring 22 criteria, so when you put together your 23 technical application there are a few things to 24 keep in mind, and this is how points will be 25 accrued for each applicant. You want to ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 25 1 demonstrate that you're providing new or 2 enhanced primary care, that you're responsive, 3 and you provide a documented need for primary 4 care in your service area. You want to 5 demonstrate that you have the qualifications 6 and the competency to carry through in your 7 project. You want to have a responsive and 8 complete grant application. And you want to 9 demonstrate that the project is viable after 10 the grant period is over. So you have to keep 11 those things in mind when you put it together. 12 Let's see, go through a couple of the 13 application pieces. Executive summary. I want 14 to emphasize the executive summary should be 15 brief. Chris has -- we have our little 16 pet-peeve about executive summaries. 17 MR. DELKER: Yeah. In past HEAL 18 iterations, we've gotten the history of an 19 organization back to the early 19th century and 20 then mission vision and value papers from their 21 last staff retreat high up on a mountain 22 somewhere, and that's all part of an executive 23 summary. And some of these executive summaries 24 run to 10 pages, you know, or more with 25 attachments. Bear in mind the summary, its ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 26 1 purpose. As reviewers, we're going to be 2 reading dozens of these things, and it goes 3 into, you know, nights and weekends. And what 4 an executive summary is, it's a good road map 5 for the reviewer, and it gives him or her a 6 good idea of what lies ahead, and it really 7 helps a lot, when we're reading the 8 application, the main components of it. So 9 keep it brief. Keep it to the point. Keep it 10 concise. No more than two pages, please. And 11 if you can do it in less, so much the better. 12 MR. SCHMIDT: Okay, community 13 need. We want to see documented community 14 need, and the RGA -- the application template 15 of the RGA lists all of the different 16 possibilities for demonstrating community need. 17 And, actually, while Neil was discussing the 18 PQI navigator, that's another area that is a 19 way -- I'm not sure. We talked about that 20 might be accessible during this application 21 process as a way to demonstrate need, so you 22 have to watch for that. But it includes things 23 like documenting the demographic data for the 24 residents of your area, have status 25 information, morbidity/mortality indicators, ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 27 1 the prevalence of chronic disease, the rate of 2 hospitalizations for preventable conditions. 3 What's the insurance level in your area? How 4 do you plan to address that? What's the 5 Medicaid use area in your area? Again, the 6 application is more detailed, but we're looking 7 to have a clearly demonstrated -- you'll score 8 higher if you can demonstrate need. 9 MR. DELKER: Yeah. And I think 10 another thing, if there are other providers in 11 your area, you know, tell us why they're not 12 doing the job, and you will. You know, in many 13 areas that's not going to be a problem because 14 it's underserved in areas, and there aren't 15 enough primary care resources, but we've seen a 16 lot of applications over the years from areas 17 where there are many D&Ts. And Jim touched on 18 this about connecting people to services 19 properly. More D&Ts aren't the problem. The 20 problem is ways to get people to those services 21 or get those services to the people. So show 22 how your activities complement or support those 23 of other providers, what you will contribute as 24 distinctive that they're not doing. Show us 25 that you know your service area in all ways ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 28 1 including what other providers are or are not 2 doing. 3 MR. SCHMIDT: Objectives and 4 timeline. For objectives you want to list your 5 process objectives and then define your outcome 6 objectives. So the process objectives 7 basically have to do with the mechanics of the 8 project, where your outcome objectives is 9 showing, how you are going to increase access 10 to primary carry or lower the amount of people 11 in your area that aren't receiving adequate 12 primary care, or if you're going to address a 13 chronic disease condition and how you're going 14 to help manage patients with that. So that has 15 to be defined under objectives. 16 The timeline, we like to see a timeline 17 that is broken into quarterly milestones. The 18 actual grant will run about two years. We're 19 hoping that we can contract starting in August. 20 We want to see timelines that say at month 21 three, at month six, at month nine. We like to 22 do vouchering on a quarterly basis. The RGA 23 says we would voucher -- or we would accept 24 vouchers no more frequently than once a month, 25 but the standard rhythm is quarterly. I mean ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 29 1 if there was a situation where you need 2 reimbursement, we would consider a more -- you 3 know, processing a voucher more often than 4 quarterly, but just so that you understand what 5 we're going to be looking for in these work 6 plans and budget outlines. 7 Monitoring plan. We like to see a good 8 monitoring plan. Historically, this has been 9 the weakest area of a HEAL application. People 10 don't seem to really think through how they're 11 going to monitor their project. And there are 12 two ways to look at monitoring. Let's say with 13 a construction project you want to be able to 14 have an effective monitoring system to know 15 that piece A is going to happen, and then piece 16 B, and what you're going to do if there is a 17 problem with piece C. So there's the nuts and 18 bolts of the construction process, but then 19 there is also program monitoring. How will you 20 ensure that you will reach your target 21 population? How will the project ensure that 22 you will accomplish the goals that you set out 23 in the beginning and how you're going to 24 monitor that? What are you going to do if you 25 have problems along the way? One thing that ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 30 1 we're going to require is that progress reports 2 need to be sent to us for three years after the 3 contract term expires, so there is going to be 4 a post-contract monitoring period, and that 5 should be addressed in your application as 6 well. 7 Project budget. Your project expenses 8 and justification need to be completed. There 9 is a schedule in the application. It talks 10 about project budget. And my next slide is 11 also about project fund sources. There is no 12 match required, but that's where you would list 13 your other project funds. I don't plan to talk 14 about this. I wanted to sort of open it up for 15 Larry from DASNY, and Tracy if they wanted 16 to -- and Charlie Abel, who are our financial 17 experts on the panel, if they wanted to add 18 some comments regarding the financial 19 application. 20 MR. ABEL: Probably, the best 21 guide or road map for putting together a 22 quality application from a financial 23 perspective is in the RGA. If you have it with 24 you, it's on my page 30. It breaks down the 25 financial and basically mirrors very closely ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 31 1 what we consider from a scoring perspective. 2 The project budget adequately -- actually, I 3 shouldn't say adequately -- completely 4 describes in sufficient detail for us to be 5 able to make an assessment as to why each 6 budget line item is necessary for this project, 7 that's substantiated from a reasonableness 8 perspective. Provide all your assumptions with 9 respect to the budget. 10 Project funding sources. Indicate all 11 of those funding sources. One of the key 12 elements here, even though Bob said there is no 13 match required, that is your project can be 14 fully funded by the grant, but a key element to 15 all of these HEAL procurements is the notion 16 that HEAL funds may not be used to supplant or 17 substitute for other sources of funds already 18 available to the applicant. Clearly, if you 19 have available funds to support the project and 20 you're committing those funds to this project 21 in connection with the HEAL applications -- in 22 connection with the HEAL grant allocations, I 23 think you have a stronger project, and I think 24 the scoring is going to ultimately reflect 25 that. ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 32 1 Cost effectiveness of the project. 2 We're looking, as Bob mentioned before, to make 3 sure that you have a viable and effective 4 project. Cost efficiency is important. We 5 want to make sure that the dollars that are in 6 that area being allocated to the project are 7 going to be used effectively and efficiently. 8 Generally speaking, you can understand that if 9 we're funding a project that is with minimal 10 grant funds and we're getting a maximum result 11 from that initiative, that would be a desirable 12 project that we want to fund. A hundred 13 million dollars is a lot of money in anybody's 14 neck of the woods, but you would be surprised 15 at how quickly those dollars do go. And I 16 think from our perspective we want to make sure 17 that we are getting the most bang for the buck. 18 I think we're going to have a lot of 19 applications submitted. I think we're going to 20 have a lot of quality applications submitted, 21 and I think we will want to fund as many of 22 those projects as possible. 23 The project that shows, demonstrates 24 financial viability, that you'll be able to 25 start this initiative. You have the necessary ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 33 1 funds in place to start the initiative. 2 Obviously, HEAL grant funds are available for 3 that purpose. And that at the end of the day, 4 when this project is up and running, it's 5 sustainable. And I think your work plan and 6 your budget is going to -- should demonstrate 7 to us very clearly that it's a sustainable 8 project, and, of course, that goes hand in hand 9 with the applicant's financial stability. To 10 the extent that you, as an applicant, or you, 11 in concert with a group of other stakeholders, 12 can present a project plan and you're 13 demonstrating that you or your group has 14 financial stability and you have the 15 wear-with-all to do this and support the 16 project, that can only enhance your scoring. 17 MR. SCHMIDT: Thanks, Charlie. 18 MR. VOLK: I just wanted to really 19 step back from it and suggest that you might 20 want to consider your financial application as 21 much of an advocacy document as the technical 22 application, because we'll have separate 23 reviewers so that the financial reviewers will 24 not necessarily see your technical application. 25 And you also want to advocate why you're doing ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 34 1 whatever it is you're doing the way that you're 2 proposing to do it and spending the funds that 3 you're proposing to spend. If you need a 4 widget, a piece of equipment, what is that 5 equipment going to do for you? How is 6 purchasing that equipment going to further your 7 providing quality primary care? So that each 8 piece of it, from my perspective as a reviewer, 9 it's what is it that you're proposing to spend 10 the money on? Why do you need it? What is it 11 going to do for you? What's the return going 12 to be not only to your organization and health 13 care in your community but also to the State in 14 terms of the State health care delivery 15 process? 16 MR. SCHMIDT: Thanks, Larry. And 17 Larry brings a good point. Just to reiterate 18 that, the technical review team is separate 19 from the financial review team. You can't have 20 financial information in your technical 21 application, so each, in a way, need to be able 22 to stand alone. You have to make your 23 arguments to both sets of reviewers. 24 MR. ABEL: Just one more thing, 25 and I'm glad Larry brought it up, and I'm going ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 35 1 to just echo it. Return on investment I think 2 is an important clause -- an important concept 3 here especially with respect to the financial 4 review. You know, we're going to want to see 5 that these dollars are invested wisely and your 6 own dollars are invested wisely and we're 7 getting something in return. Obviously, 8 improving health care is the main focus here, 9 but that also speaks to sustainability of the 10 program as well, to the extent that the 11 initiative makes sense from a financial 12 perspective is important as well. 13 MR. SCHMIDT: Thanks, Charlie. 14 Okay, the last slide. Oh, separate technical 15 and financial applications. You have to submit 16 two originals signed. You have to also submit 17 four photocopy sets, and then six CDs or flash 18 slides with PDF images of a copy of your 19 application, which we've launched a new review 20 process internally. It's DocuShare, which 21 basically the reviewers can access applications 22 electronically. In the past, I don't know if 23 anyone remembers Phase 2, but we asked for 21 24 photocopies of applications, so this cuts down 25 on it substantially and makes our job a little ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 36 1 easier. 2 So those are the requirements. The 3 applications are due by 3 p.m. on April 17, 4 2007 -- I'm sorry, 2008. And our Q&A is -- 5 questions can be submitted until February 22, 6 2008. And you can e-mail it to 7 healnewyorkprimarycare@health.state.newyork.us, 8 and that's in your RGA. And then we should be 9 able to -- the panel will assemble and answer 10 the questions, and they'll be posted on our 11 website hopefully within two weeks after that 12 date. And we'll start the question and answer 13 process. Joe and Janice will -- I'll let 14 Chris. 15 MR. DELKER: Did we miss a slide, 16 oh, the competitive procurement slide? Oh, 17 yeah, because this is a competitive 18 procurement, your application has to be judged 19 as submitted. You cannot call us later and say 20 I want to clarify something in section 5 or 21 take out sentence 2 on page 6 or something like 22 that. Your application is going to be 23 stand-alone, and it's what the reviewers will 24 see, so make it as self-contained and as 25 precise and as thorough as possible because you ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 37 1 can't do any follow-up with this or call us or 2 anything like that once it's submitted. 3 We'll start the question and answer 4 now. The ground rules are these: There are 5 people coming around with microphones, so just 6 raise your hand, and they will come to you in 7 order, and you can ask from where you're 8 sitting. And you can ask one question and, if 9 necessary, a related follow-up, so don't say 10 I'm going to ask two questions right now. If 11 it's related to the response, you can ask a 12 follow-up. We'll do that once for everybody. 13 If everybody has taken a turn at the first 14 question, we will then entertain second 15 questions until -- and we'll do that until 16 we're done or until we all get so hungry for 17 lunch that we don't want to stay here anymore. 18 So and we're doing the phase 7 at 2:00, so we 19 can't stay here late. 20 I think the first question is over 21 here. 22 MR. POFIT: Thank you. Joe Pofit 23 with Catholic Charities. Just a question about 24 the wisdom behind not including any working 25 capital requirements as part of the grant. ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 38 1 Just adding capital may be one thing, but a lot 2 of these projects require, say, some help for 3 the first year, the second year, so I think 4 you've got some very interesting applications 5 that way. If anybody comment on that? Thank 6 you. 7 MR. VOLK: I'll take the first 8 stab at it, and that is it's fundamentally that 9 it's a capital program. It's a capital grant, 10 and our funding sources are fundamentally 11 capital funding sources. However they are 12 derived, whether it's bond groceries or state 13 appropriation, there still is a capital nature 14 to them. Working capital is fundamentally an 15 operating issue. It is a short-term investment 16 that is expected to come back and provide a 17 pool of cash for the ongoing operations. And I 18 don't mean to minimize that, but from a capital 19 investment perspective it's not really 20 considered to be true capital. 21 MS. COOKE: Good morning. 22 Jannette Cooke from Sound Shore Medical Center 23 in New Rochelle. 24 MR. DELKER: Would you hold that a 25 second? We're having a sidebar here in ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 39 1 relation to the last question. 2 MR. VOLK: One distinction that 3 probably should be identified is sometimes 4 start-up costs are considered to be working 5 capital costs. And to the extent that we can 6 identify them as start-up costs, we may very 7 well be able to reach them. 8 MS. COOKE: Yes. A different 9 question, please. I believe I heard 10 Mr. Benjamin mention that the dollars could be 11 used for not only capital projects but also 12 management system improvements. And I just 13 wondered if you could talk a little bit more 14 about that so I can understand it please. 15 MR. DELKER: Mr. Benjamin doesn't 16 recall saying that. 17 MR. BENJAMIN: It wouldn't be the 18 first time. 19 MR. DELKER: I think perhaps were 20 we talking about information systems? I think 21 that may have been a reference to information 22 systems which, if it can be demonstrated that 23 those are helpful in enhancing primary care. 24 Remember, this is about getting services to 25 people. If you're investing in some ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 40 1 information systems that will help you operate 2 more efficiently and thereby see more -- you 3 know, have more visits, see more people, reach 4 out to more of the population, that would 5 certainly be compatible. But bear in mind, as 6 we say in the RGA, don't make these big HIT 7 applications because they're health information 8 technology. There are iterations under HEAL. 9 Over $150 million has been let so far, has been 10 put out for bid so far. So if you have a major 11 HIT project, that is supposed to be in some of 12 the other HEAL iterations. This is about 13 enhancing or expanding services, so to the 14 extent that you asked for IT, it has to be to 15 that end. 16 MR. BENJAMIN: Chris, on that I 17 don't really recall saying it that way, but 18 you're right. Let me see if I have this right. 19 I'm having difficulty even turning my computer 20 on. But if there are peripheral interfaces 21 that are integral to the patient care delivery 22 project that you have, those will be 23 considered. But, again, as Chris said, it's 24 not the primary objective of the procurement. 25 However, if some IT work is incidental to ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 41 1 achieving your goal, it will be considered. 2 MS. YEE: Hi. Maureen Yee, St. 3 Peter's Hospital. We have multiple primary 4 care sites. Can the application address 5 multiple sites, or would you prefer to see just 6 the focus on one? 7 MR. DELKER: Multiple sites would 8 be fine. I mean, you know, as long as you're 9 meeting the goals of the RGA, there is nothing 10 that says that it has to be targeted to one 11 site. 12 MS. SCHMIDT: Julie Boden Schmidt 13 with Family Health Network of Central New York. 14 Given that some of this is capital money, are 15 there any parallel efforts made to streamline 16 the Certificate of Need process? 17 MR. BENJAMIN: Yes. No, similar 18 with other procurements, we will be, to the 19 extent we can, prioritizing the coordination of 20 CON approvals so that, you know, your project 21 is not held up due to DOH processing. 22 Unfortunately, the HEAL statute doesn't exempt 23 CON review, but we already have databases for 24 each of the HEAL procurements that parallel 25 track the status of the different types of ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 42 1 approvals that are needed. And that's a very 2 good point, and we're trying to focus in on 3 that to make sure there are no unnecessary 4 delays. 5 MR. GILBERT: Jeff Gilbert, New 6 York State Affiliates of Planned Parenthood. I 7 have a question about the definition of primary 8 care as it pertains to eligible applicants. 9 Mr. Delker said specialty care is not primary 10 care. 11 MR. DELKER: Family planning is 12 primary care. 13 MR. GILBERT: Thank you very much. 14 MR. DELKER: This department has 15 long considered it primary care. 16 If there are other questions -- who's 17 next? There are some over here. 18 MS. REHAH: Pamela Rehah, Seton 19 Health. So that on 2:00 on the day this is due 20 we're not having this debate, the question 21 about how many CDs you need and how many 22 copies, is it actually twelve CDs, six of the 23 technical and six of the financial? 24 MR. DELKER: Yes, two complete 25 sets. Remember, the technical reviewers will ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 43 1 not read the financial and vice versa, so they 2 have to be two complete sets. 3 MS. REHAH: It says the complete 4 application. That's what threw me. 5 MR. DELKER: Whatever. 6 MS. WALTERS: Hi. Ruth Walters 7 from the New York State Association of Academic 8 Dental Centers. You clarified the fact that 9 D&T centers include dentists. One of the 10 questions we have is whether or not an 11 association or a not-for-profit could apply on 12 behalf of the Article 28s? 13 MR. DELKER: No. 14 MS. WALTERS: Okay. 15 MR. VOLK: Just a second. Chris, 16 do you want to expand on that just a little 17 bit? 18 MR. DELKER: Expand on it? No. 19 MR. VOLK: Can we stick several 20 syllables in between the first and last one? 21 MR. DELKER: Go ahead, please. 22 MR. VOLK: While the non-profit 23 organization that is not an Article 28 could 24 not be the applicant, certainly any project, 25 such as an association or organization might ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 44 1 wish to promote, could be sponsored by an 2 eligible applicant which would be one of those 3 members, one of the D&Ts, which then could act 4 on behalf of all of them. 5 MR. DELKER: Right, but that 6 single Article 28 provider would have to be the 7 lead applicant, and it would be that one that 8 would engage in the contract and be responsible 9 for all activities under the contract. 10 MS. WALTERS: Can I ask another 11 question then? 12 MR. DELKER: Yeah, absolutely. 13 MS. WALTERS: So does the cap 14 apply then, the regional cap, to the D&T center 15 itself? Again, if you have a consortium does 16 that cap apply on a regional basis? In other 17 words, does the cap apply regionally, or is it 18 a $5 million cap no matter what? 19 MR. DELKER: The project would 20 cross regions, is that what you're saying? 21 MR. CLYNE: Yeah. I think we 22 would like to talk about that a little bit more 23 internally, but at least in one conversation 24 we've had, each of the projects would have to 25 be judged in their region. So they would be ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 45 1 looked at as projects in the region unless 2 there was if you had a single applicant, and I 3 think all of the single-applicant issues are 4 going to have to apply, so it depends on how 5 you submit that single applicant. Then all of 6 the single-applicant rules would apply there. 7 If it's the same type of proposal with 8 different individual applicants in each of the 9 regions, then it would be judged by each of the 10 individual applications coming in that region. 11 MS. WALTERS: So would a single 12 applicant have a $5 million cap? 13 MR. DELKER: Yeah. 14 MR. CLYNE: Yeah. 15 MR. BURKE: Greg Burke from 16 Montefiore. I'll narrow it down to one 17 question. 18 MR. DELKER: That's hard. 19 MR. BURKE: Right. The primary 20 care definition as internal medicine, 21 pediatrics, family medicine only, and the care 22 of the complex patients and whether or not 23 you're doing something to help the primary care 24 practitioners care for patients who require 25 health education or that require some manner of ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 46 1 improved access to specialty services, which is 2 a non-trivial issue certainly where we live, 3 how hard and fast is the line about no 4 specialty services? Because in many ways 5 that's what enables the primary care 6 practitioners to manage complex, multi-problem 7 patients better, having better access to that 8 stuff. 9 MR. DELKER: Well, I'll take one 10 crack at it and ask the rest of the panel. I 11 think what we would not fund would be a regular 12 ongoing source of specialty care if the 13 applicant site and the applicant were proposing 14 to provide, you know, say cardiology or 15 something on an ongoing basis, and that's the 16 main reason for those visits, then that would 17 not be considered. That would be considered 18 specialty care and not primary care. Anyone 19 else? 20 MR. LAUDATO: I think that instead 21 of thinking about this in terms of the 22 discipline of the physicians involved, I think 23 there is a concept of primary care, which is 24 the ongoing relationship that accepts 25 responsibility for the patient's overall health ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 47 1 and well being. It's a little different in the 2 context of a capital program. You know, 3 building, expanding primary care comes along 4 with it, you know, the availability of certain 5 hours of coverage, all of the things that are 6 built into the context of primary care. I 7 don't think there is anything within this that 8 says, you know, you can't have specialty 9 support occurring in those areas to meet the 10 primary care needs of those patients. 11 MS. LAROWE: I have a gymnasium 12 voice. I don't think I need a microphone. 13 MR. DELKER: Well, the rest of the 14 people should hear you. 15 MS. LAROWE: Maybe I can just add 16 to the question. I'm Mary LaRowe from St. 17 James and Hornell. But if you were to 18 consolidate some of your primary care practices 19 into one site, which would include some of your 20 specialty physicians that the primary care docs 21 refer to frequently, also laboratory and 22 perhaps imagining, is that something that would 23 be considered too heavily weighted on the 24 specialty side versus the primary care side if 25 there is a good referral pattern that you can ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 48 1 demonstrate in the application? 2 MR. DELKER: I think we would look 3 at the projected volume of visits and how many 4 of those would be primary care visits, you 5 know, in the sense of that word, versus the 6 specialty visits. I think that would be -- we 7 would have to look at that. Certainly, 8 laboratory equipment and associated capital 9 costs are eligible. Imagining equipment, those 10 are eligible costs under this RGA. Jim, did 11 you want to add to that? 12 MR. CLYNE: You would also have to 13 go back and show how you expanded primary care 14 for what is the identified population. So is 15 there an identified lack of primary care for 16 people with diabetes in your area? And if in 17 some way you can show the connection or the 18 expansion of primary care to that population, 19 then it's going to score higher, and if it's 20 related to some specialty care that's probably 21 okay. 22 MR. DELKER: Also, I would caution 23 you. I'm not sure exactly what model you're 24 talking about, but if it's just conversion of 25 physician practices and it's going to be, you ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 49 1 know, just a change in the roof of the lobby, 2 that's not a new -- you know, an expansion of 3 primary. It's not eligible under this RGA. 4 MR. SENN: Larry Senn, WCA 5 Hospital. Under Section 1.3.2 there is 6 enhancement to existing primary care. These 7 spoke to transition from emergency departments 8 into ambulatory care settings including urgent 9 care centers. Would the CON and regulatory 10 process for urgent care in this application 11 fall to primary care or emergency or a whole 12 new ambulatory care -- or urgent care center 13 regulation? 14 MR. BENJAMIN: Yeah. I mean as 15 we -- you know, what I spoke to earlier up 16 there about the last five years and what we've 17 learned, we've been encouraging urgent care 18 types of arrangements so that, you know, truly 19 non-emergent hospital ED visits are prevented, 20 so to speak. We've always brought that in 21 under CON under primary care. We don't have a 22 separate -- as everyone in this room probably 23 knows, we don't have a separate licensure 24 category for urgent care. It does fall under 25 either extension clinics or D&Ts, but we think ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 50 1 we have the expertise now to identify the true 2 programmatic elements that would lend itself to 3 reviewing something either as an urgent care 4 center or as a straight, you know, outpatient 5 primary care clinic or something that may fall 6 in between. But for CON it's definitely, and 7 for this, it's definitely primary care. 8 MS. BRESLIN: Hi, Kate Breslin 9 from CHCANYS. Would projects that aim to 10 integrate primary care with behavioral health, 11 like mental health care services, be 12 considered? 13 MR. DELKER: Yes, but I'll defer 14 to Jay in a minute. I mean certainly mental 15 health is part of primary care, and we've 16 always recognized that, and certainly a 17 proportion of visits is certainly acceptable. 18 Generally speaking, a primary care D&T should 19 not be an ongoing source of regular mental 20 hygiene care for the client. That patient, if 21 he or she needs it, following an initial 22 encounter or stabilization, should then be 23 referred to some other community-based mental 24 hygiene service. I'll let Jay talk about that 25 too some more. He's better versed in this. ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 51 1 MR. LAUDATO: I would just say 2 that this is, again, a primary care focused 3 RFP. And in substantiating the need, one would 4 have to speak to the medical needs of the 5 patients and why behavioral health will 6 facilitate achieving the health outcomes of 7 those patients. I think it's important not 8 to -- you know, regardless of whether it's an 9 FQAC that has an ability to deliver a certain 10 amount of ongoing mental health services or an 11 Article 28 hospital based or D&TC to stay 12 clearly within the lines of the regulations 13 about the scope and duration of mental health 14 services, but again it's the end point of 15 primary care. 16 MR. TENAN: Paul Tenan with Seton 17 Health. If the primary care program is 18 interested in making an investment into the IT 19 tools and solutions and there is a wider 20 regional program underway about information 21 technology under auspices of other entities, 22 you know, what evidence and what suggestions 23 would you make to see, in a competitive 24 application, it was understood that this 25 program was -- or the program's proposal, I ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 52 1 should say, was going to be consistent? Many 2 of these large scale programs are under some 3 years of development and not necessarily 4 directly aligned with putting a practical type 5 of tool in place that is going to be related to 6 electronic health records, monitoring and 7 performance improvement within a primary care 8 site. So are there suggestions that you would 9 make that an applicant will consider and cover 10 so that this issue doesn't get raised on 11 review? 12 MR. DELKER: I'll take a stab at 13 it. I think you would have to show that that 14 connection is going to result in an increase 15 number of visits, better throughput so you see 16 more people, or perhaps implementation of a new 17 primary-care-related service, disease 18 management or something, having those EHRs or 19 something would do that. And, again, we would 20 look for interoperability, meeting those 21 requirements, those federal guidelines, I guess 22 they are at this point. So we would want to 23 consider that. 24 MR. ABEL: If I can just add a 25 perspective here, because I thought in that ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 53 1 question was embedded the possibility that the 2 application to be submitted under this 3 solicitation would be one that was also being 4 submitted for other initiatives. And, you 5 know, that really muddies the water with 6 respect to the reviews. And, obviously, if you 7 were to submit an application that had 8 electronic medical record components, for 9 instance, you would have to very clearly 10 indicate what, if any, other funding was 11 available or what you applied for with respect 12 to other grant opportunities so that we could 13 clearly understand and know that we are not 14 going to be duplicating any other funding 15 opportunities for that initiative. 16 MR. TENAN: No, that wasn't the 17 essence of my question. It really -- an 18 applicant who is going to develop primary care 19 services at physical capacity wants to do it 20 well in today's form, in today's tools, and 21 you've already made a sizable investment, other 22 parts of your HEAL funding, to types of 23 regional consortiums or to a medical center who 24 may be the focal point within a region for 25 sponsoring wider IT types of goals and ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 54 1 objectives. What should a viable applicant 2 demonstrate to you to say this is compatible, 3 this is not compatible? What we're going to do 4 on a specific street address for a primary care 5 center is serve basically a specific area in a 6 community is consistent and be happy to work 7 with this other entity as it develops over 8 time, but it's also on a timeline for which 9 you've already invested a sizable amount of 10 money. But most of those larger regions are 11 large awards, as I recall. So I just want to 12 make sure that if someone asks for support for 13 IT enhanced practitioners, would be more 14 effective as practitioners, somehow isn't 15 viewed as contradictory and duplicative where 16 you've already put dollars with large entities 17 that are not directly necessarily tied to 18 primary care initiatives. 19 MR. SCHMIDT: If you're referring 20 to the earlier HEAL health IT phases, the funds 21 for the earlier phases were intended to be 22 spent on inter-connectivity between 23 organizations. They were not intended -- with 24 the exception of one category in phase 5 that's 25 for EHR, the focus of the health IT initiative ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 55 1 was to connect organizations, create regional 2 health information organizations which will 3 eventually lead to a statewide health 4 information network. The reason why IT is an 5 allowable cost in this RGA is because 6 individual clinics were not eligible applicants 7 in either phase 1 or 5. So an individual 8 practice couldn't say, you know, the State of 9 New York, I'd like to have X, Y, Z funds for my 10 initiative. So this is included here because 11 it's an opportunity for an individual group, as 12 a part of a primary care expansion, to improve 13 their internal IT system. It's really, we're 14 trying to keep it separate from the earlier 15 HEAL phases. I don't know if that helps, Paul. 16 MR. ABEL: If there is an IT 17 component to your application, you should 18 certainly make sure that you demonstrate to us, 19 the reviewers, that it will be compatible with 20 other initiatives or other systems that exist 21 so that there will be interoperability. Is 22 that the word? Oh, you've got a technical 23 term, Bob? Go ahead. 24 MR. SCHMIDT: Well, it's going to 25 be should certify for interoperability, and, ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 56 1 you know, there is an improvement of software 2 by that -- 3 MR. BENJAMIN: Paul, I just want 4 to follow-up one last time on Paul's question. 5 Paul, as I think Chris and Bob tried to mention 6 earlier too, we do have to be careful still, 7 even though this is a Q and A session, about 8 just, you know, the level of detail that we try 9 to put out there. I mean I don't want to sound 10 rude by saying this, but in a lot of these 11 things we'll know when we see it. I mean we're 12 trying to put out there the over-arching 13 concepts of all of it. And again you folks out 14 there who are the providers, you really know 15 what you need to give to us. You have a better 16 sense than we do. Again, though, on what I 17 said earlier about IT and whatever I said about 18 peripheral something or other, those things 19 again they're not the main goal of this 20 procurement, but if they are -- you know, if 21 they are tangential or whatever the words are, 22 you know, we certainly will consider it, 23 because we're not -- again, what we've 24 learned -- I keep going back over the last five 25 years. What we've learned is there can be ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 57 1 equal, if not more, merit to a project that 2 improves the delivery of services by existing 3 providers rather than just adding more sticks 4 and bricks or equipment or whatever. So we're 5 really looking for you, and, along with us, 6 with some of the data we can help you with, to, 7 you know, tell that story. 8 MR. DRISGULA: Paul Drisgula, 9 Planned Parenthood, Mohawk Hudson. This is a 10 timing question. If a project is well advanced 11 in its planning and is near start-up and maybe 12 actually post start-up by the time contracts 13 are awarded, does that project still qualify? 14 MR. DELKER: Generally speaking, 15 no, because presumably you already have the 16 funding for that. HEAL funds cannot be used to 17 supplant or replace other sources of funds. 18 So, presumably, if you're about to start-up 19 you've got your credit, your loan, or whatever 20 financing you have, so no. 21 MS. SPEEDY: Gail Speedy, 22 Universal Primary Care. Along those same 23 lines, would there be an opportunity to look at 24 preservation of services especially in areas 25 that are rural and HIP -- designated? ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 58 1 MR. ABEL: Well, I'm not strong on 2 the programmatic aspects, but I would -- 3 generally speaking, in thinking of the overall 4 intent of this solicitation, I would think that 5 we would be able to entertain applications for 6 maintaining services in a certain region where 7 there is need where otherwise both services 8 would be threatened. I guess we would have to 9 take a look at your application and how it 10 merits in relation to other initiatives. You 11 know, ongoing viability is clearly a concern. 12 If you're having trouble meeting -- if you're 13 having trouble in a certain area surviving and 14 being able to maintain viability now, are these 15 grant funds only going to keep you out there 16 for a couple more years? What's the likelihood 17 that this investment is going to be able to 18 keep that resource into the future? 19 MR. DELKER: And bear in mind, 20 this is for capital projects. You know, if 21 you're losing operating funds or things to 22 support staff, I mean that really wouldn't 23 speak to the general purposes of this grant. 24 MS. ARMNTER: Ann Armnter from 25 Health Quest in Poughkeepsie, New York. Just ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 59 1 to clarify on two questions ago on replacement 2 of funds. The grant can be used to reimburse, 3 however, can it not, if we're setting up the 4 application, borrowing money primarily to get 5 moving on the project with the hope that we 6 are -- if we're not we'll find other resources, 7 but if the plan is to reimburse ourselves with 8 grant money is that acceptable? 9 MR. DELKER: Well, the project 10 would have to be something totally a new 11 initiative out of this application. Are you 12 talking about, you know, getting an advance on 13 the project? 14 MS. ARMNTER: No. We would be 15 going ahead and putting money down on it and 16 applying for the grant at the same time, hoping 17 to reimburse ourselves for some of the 18 expenses. 19 MR. DELKER: I don't think so, 20 because if you're putting money down on it 21 you're already funding it. 22 MS. ARMNTER: We're borrowing it. 23 MR. DELKER: Well, but you still 24 have the wear-with-all to borrow it, so we 25 would be replacing other money that you got ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 60 1 before the project was even looked at here. 2 MS. ARMNTER: Okay, thank you. 3 MR. RUBINSKY: A new question. 4 Steve Rubinsky, ARC Health Resources of 5 Rockland. We're a voluntary agency. I notice 6 in the RGA that there is an expectation that 7 prevailing wage be paid on any construction. 8 Does the Wicks Law apply in this case? 9 MR. DELKER: No, Wicks does not, 10 but the prevailing wage law does apply. And 11 that brings up a good point. That's in the 12 HEAL legislation, and I don't know how many of 13 you are familiar with it. I wasn't until I 14 started working on this. The Department of 15 Labor has schedules for each county and I think 16 in each village and hamlet in the State. We 17 printed out the whole prevailing wage schedule, 18 and we had to use three reams of paper to do 19 it, but your local Department of Labor office 20 will be able to advise you on what the wage 21 scales are. And this is an important 22 consideration in capital projects because it 23 affects mainly the construction building 24 trades, labor forces. 25 MR. NAZAR: Mike Nazar, Unity ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 61 1 Health. Can you talk a little bit more about 2 the differentiation of relative weight of 3 enhancement versus expansion of services? 4 There has been discussion I think of both of 5 throughput and also of enhancement services. 6 MR. DELKER: Well, I guess we'll 7 know it when we see it. I think they're kind 8 of interchangeable. I think if you want to -- 9 for example, if you want to purchase an 10 additional imagining device so that you can 11 render those services as part of primary care 12 to a large number of people, you're enhancing 13 your existing capacity, okay. Expansion, I 14 would see something like, you know, adding 15 additional procedure rooms or something like 16 that, and so you're serving 1,500 visits in X 17 amount of time. If you have an additional 18 procedure room, you'll be serving 2,000. I 19 mean you're expanding capacity. I think, you 20 know, it's kind of nuanced. It's making it 21 better, you know. But I think expansion would 22 refer to service volume. Enhancement might be 23 more on the lines of efficiency, but presumably 24 that efficiency would lead to more care for 25 more people. ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 62 1 MR. LAUDATO: I would just say 2 that again data is very important. Data is 3 extremely important -- data about missing need 4 within a community or waiting times or poor 5 outcomes that can be achieved. I think the 6 intent is really to improve the health of the 7 community, and in some ways that's expansion, 8 and in other ways that is actually new 9 programs, but I think data will drive the 10 decision-making. 11 MS. BRESLIN: A follow-up to that. 12 Kate Breslin again. And, Neil, I hate to put 13 you on the spot. 14 MR. DELKER: Kate, can you wait? 15 You've asked one question already. We need to 16 go around. 17 MS. BRESLIN: Sorry. 18 MR. DELKER: Thank you. 19 MR. BENJAMIN: Thanks, Chris. Put 20 the hammer down. 21 MR. MURPHY: Yes, Tom Murphy, 22 Primary Development Corporation. Would program 23 monitoring costs, a consultant be considered 24 eligible costs? 25 MR. BENJAMIN: Absolutely. ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 63 1 MR. DELKER: Yeah, they're 2 eligible, but again, you know, we want to show 3 more services to more people, and if you can 4 relate it to that, better outcomes, yeah. 5 MR. BENJAMIN: Maybe draw from 6 something that is in the reimbursement 7 regulations -- necessary, reasonable and in the 8 public interest. You know, to the extent that 9 the consultant costs are necessary and 10 reasonable, yes, they are eligible costs. 11 MS. SULLIVAN: Jennifer Sullivan 12 from St. James. I have a question, a follow-up 13 question to the timing. I'm trying to get my 14 arms around, you know, if you think about how a 15 project comes together and all the steps that 16 parallel, you know, your strategic planning and 17 putting together CONS and all of those things, 18 and inherently you're already funding some 19 pieces to get it moving, and you have a draft 20 plan of finance but you're really not sure 21 where that's going -- or if you'll get that. 22 So would that type of project be considered 23 under this type of application? Can you run 24 these parallel tracks, and how do those dots 25 connect? ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 64 1 MR. ABEL: I'm glad you asked that 2 follow-up question, and it's probably going to 3 be a panel answer, at least I welcome it to be 4 a panel answer. I think from the perspective 5 that you can demonstrate that you've done 6 planning, you've got a project that's ready to 7 hit the ground running, I think that's a 8 positive aspect. Balance that with what we've 9 talked several times about already, that HEAL 10 funds can't supplant other sources of funding 11 including borrowing. You know, the borrowed 12 funds is a source of funding just as if you put 13 cash into a project. So when we take a look at 14 your project from a financial perspective, you 15 know, we're going to take a look at what you're 16 asking for with respect to the HEAL grant, the 17 reasonableness and the necessity of all of the 18 budget items, what you have as an organization 19 or what you have at your disposal. Associated 20 entities that may support your project are 21 potential sources of funding as well, and your 22 ability to access loans to support your project 23 will be reviewed as well. So we want to make 24 sure that again the dollars invested from the 25 HEAL perspective are wisely used and that ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 65 1 they're not -- that you've considered all 2 available funding sources and you need 3 something to make this initiative work, and 4 that's where the HEAL dollars are going to be 5 there, to kind of plug that gap. And that's 6 basically how we're going to take a look at 7 your overall project budget in front of you. 8 MR. CLYNE: I think there are 9 going to be lots of nuance in this one, but the 10 one thing that's clear is if you've already 11 filed a CON and we've already said that it's 12 financially feasible without funding, then 13 you're not going to be eligible. The next step 14 back from that would be that if you've done 15 everything but file a CON and it appears that 16 the project would go on with or without HEAL 17 funding, I'm not sure that we would then 18 contribute it. And then I think you start 19 sliding then into a gray area where we 20 understand that you're going through a process 21 to try and move a project forward, and then 22 it's going to be a judgment call as reviewers 23 go through -- how good is the project, what's 24 the chance of it going forward without HEAL 25 funding. ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 66 1 MR. STALEN: Bob Stalen with -- 2 Health Care. With respect to the question on 3 preservation of services and also improvement 4 of management, could the moneys be used by one 5 Article 28 to purchase the assets of another 6 Article 28 and reorganize the primary care 7 services that might be involved in whole or in 8 part? 9 MR. BENJAMIN: Yeah. 10 MR. CLYNE: Again, we're going to 11 keep coming back to the same thing, which is 12 it's going to be able to expand or enhance the 13 primary care capacity. So if part of the 14 reorganization meant that without this, you 15 know, resource was going to be totally lost in 16 the community and there is some viable plan 17 moving forward, then we would consider it. 18 MS. MARSHA: Chris Marsha from 19 Smith House Health Care Center. In regard to 20 the expansion of existing buildings that we 21 have, do you require an architect's stamped 22 drawing, or can it be just a schematic? 23 MR. ABEL: A schematic is fine. 24 When theoretically that project would require a 25 CON, eventually we'll get into more detail on ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 67 1 that level. 2 MS. ROACH: Karen Roach from 3 HANYS. I just have a question about the timing 4 of making the awards. I'm sure it will depend 5 on how many applications you get, but do you 6 have a timeline on when you hope to get some 7 announcements out on this? 8 MR. DELKER: Well, the 9 applications are due in mid April, so, you 10 know, probably around the 1st of July or so, we 11 hope to get the announcements out. The 12 contract periods are projected from August 1. 13 You know, that might be kind of tight, but 14 certainly you can have contracts retroactive to 15 a certain date, as we have done in most of the 16 HEAL activities so far. But, realistically, as 17 the applications come in, depending on how many 18 we get -- in the middle of April, there is 19 usually a period of a couple of weeks filtering 20 them through to determine eligibility, and then 21 getting them out to the reviewers, and then the 22 scoring and the waiting, and then developing 23 the composite scores, so probably late June, 24 early July would be the announcement time. 25 MS. TYLER: Virgina Tyler with ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 68 1 Tyler Consulting. A question about shared 2 services or collaborative arrangements. What 3 sort of documentation are you looking for to 4 indicate that collaboration? 5 MR. BENJAMIN: It could range. It 6 could range from -- it would all depend upon 7 the nature of what you're trying to do. It 8 could range from anything from something as 9 simple as a loose affiliation, if that's 10 necessary to do it, all the way up to something 11 that may trip a governance requirement under 12 Article 28 that could require, you know, a 13 co-licensure. So anything, anything in between 14 we'll consider -- an affiliation or an 15 administrative services agreement, you know, 16 all the different types of things that would 17 run the gambit. We're not wedded to one or 18 limiting it to one. Again, it all depends on 19 how effectively you think you will be able to 20 accomplish the goals of the RPA. 21 MR. EHRLICH: Hi. Marnie with 22 Gem's Consulting. I had a question about 23 training and things. If there was a training 24 activity that specifically helped efficiency, 25 would that be covered in this? ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 69 1 MR. ABEL: You know, well, let me 2 just make a general overlying comment here. 3 You know, efficiency by itself is fine, but I'm 4 not sure it gets at the actual intent of this 5 initiative, which is to improve health care 6 outcomes and access to health care in areas 7 where it's lacking. I would hate to see a 8 number of applications come in to build an 9 infrastructure that is not adequately tied to 10 those main goals. I'd hate to see applications 11 come in for reorganization of existing 12 facilities that doesn't clearly meet those 13 objectives. I think a lot of things can be 14 considered, submitted and considered as part of 15 an application for these funds, but you've got 16 to tie them very clearly to those goals. 17 MR. DELKER: And bear in mind this 18 is a competitive process, that the applicants 19 that write a good application that addresses, 20 you know, what we said -- improving health 21 outcomes and health status -- are going to fair 22 better than a single kind of narrowly-focused, 23 single-purpose application. There are going to 24 be a lot of other people out there in your 25 region asking for the same money. If the past ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 70 1 is any guide, we'll get four to five times the 2 volume, the dollar amount requested as we're 3 able to give out. So think very carefully 4 about adhering to the objectives and principles 5 in the RGA. 6 MR. BENJAMIN: Chris, though, to 7 the specific question about training, if 8 training of personnel is necessary to achieve 9 the objective -- and I just make an example. 10 If there are rural areas up in the Adirondacks 11 that are without care and there are specific 12 skills that providers or support staff need to 13 have to reach that population, certainly that 14 type of thing I would think we would have to 15 consider. Again, though, the balance, you 16 know, the balance of the money inside your 17 project is also something that we'll pay 18 attention to. You know, your efficiency, as 19 Charlie said, and ability to manage through 20 this is going to be balanced against our view 21 of, you know, reasonable project components. 22 Chris keeps hammering home that this is 23 basically a capital-focused program, and so 24 these other types of things that we talked 25 about -- start-up costs or training or ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 71 1 whatever -- again will be considered but only 2 to the extent that they are absolutely 3 necessary to meet the goals and objectives, 4 not for, you know, the ability to potentially 5 put in training costs for other programs that 6 you may have inside your organizations or 7 whatever. We're going to focus this directly 8 and specifically on the primary care piece. 9 MR. DELKER: All right, is there 10 anyone who has not yet asked a question who 11 wants to? Okay, is there anyone who has asked 12 a question and would like to ask another one? 13 We can only do this until noon despite what I 14 said earlier about working through hunger, 15 because that's the time we posted -- 10 to 12 16 noon -- so by law we have to adhere to that. 17 MS. BRESLIN: I'm just curious 18 about when the PQI navigator might be live. 19 MR. BENJAMIN: Should I use 20 seasons of the year, or months, or, as Larry 21 said, the meaning of life? Seriously, we're 22 really -- I mean it's such an important tool to 23 the Commissioner and to everybody. The testing 24 phase has been very intense, and we hope to see 25 the draft final product. I mean it came back ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 72 1 with a whole bunch of bugs in it, so we're 2 hoping -- we're really hoping by, you know, the 3 middle of this month. I mean we really want to 4 make this as available as we can, to help 5 everybody, you know, develop their 6 applications. So can't commit to it, but we're 7 pushing it. 8 MR. DELKER: Anybody else? 9 Greg. 10 MR. BURKE: Greg Burke from 11 Montefiore. How many applications can you send 12 in or a given provider send in? Not that we're 13 thrilled about the idea of doing this whole 14 thing more than once. 15 MR. DELKER: Well, I can assure 16 you, I'm not trilled about reading more than 17 one of your applications either. 18 Well, I guess there is nothing to 19 prohibit you from submitting more than one but, 20 you know. 21 MR. BURKE: Specifically, it was 22 around the small large thing and whether or not 23 you're -- 24 MR. DELKER: Well, you're going to 25 be competing in a region, and, you know, there ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 73 1 may be some consideration to if there is a 2 numerical score, but sometimes within a region 3 rarely is there enough to go around for 4 everybody. It may be considered that you 5 already got one in anyway, you know, so I can't 6 tell you not to do it, but I'm being -- 7 MS. HEFNER: Chris, if you submit 8 more than one, the issue becomes they can't 9 later withdraw one and -- 10 MR. DELKER: If you submit -- I'm 11 advised by Marybeth Hefner from the Bureau of 12 Accounts Management, that if you submit more 13 than one, you cannot later withdraw one or do 14 anything to either one of them, obviously, in 15 the hope that it might make the other one fare 16 better. So when it's in it's in. 17 Is that it? Paul. 18 MR. TENAN: Paul Tenan, Seton 19 Health. I'm trying to get as clear an idea, 20 looking at the components of the expense 21 project tables and your discussions and 22 emphasis about the capital attention to how the 23 dollars are here, but there are start-up costs 24 that are not to a fixed asset that are involved 25 in any sort of project, and especially a ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 74 1 primary care one, because primary care programs 2 are viable based on the productivity of staff. 3 So if a model that would be proposed has 4 elements that are related to a non-recurring, 5 one-time type of expense -- elements about 6 quality, elements about training, elements 7 about the capacity to expand the service by 8 connecting into training programs for 9 professionals, physicians and others, are 10 examples of what kinds of strategies that could 11 be used -- are these justifiable -- I dare not 12 use the label, but I feel like there are no 13 others -- start-up costs that can be borne here 14 in a credible proposal? 15 MR. ABEL: We have the ability to 16 fund elements of the project that are not 17 strictly capital. So the short answer, I 18 think, is yes we would be able to consider 19 applications that contain those elements. 20 MR. DELKER: Anybody else? Okay. 21 MR. TENAN: Thanks, Chris. This 22 question is about measurement of the projected 23 program income and the reference earlier to the 24 changes with Medicaid reimbursement. So what 25 guidance or what suggestions can you give to us ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 75 1 here beginning in February, the deadline April 2 17, and obviously a budget be adopted, I 3 assume, where can we expect to look that would 4 help us to think about changes in the actual 5 payment units and any qualifications for those 6 that in order to help use those for projection 7 of project income and include this in an 8 application? 9 MR. CLYNE: We don't know the 10 outcome of the budget process. We made a 11 series of incredibly thoughtful and thorough 12 proposals coming out of the Office of Health 13 Insurance Programs, but until they're actually 14 adopted, you know, we don't know for sure. You 15 can clearly see where we're going. We're 16 serious about it. We're serious about trying 17 to get it done. I'm not sure that we're 18 getting a lot of feedback that it's a bad idea, 19 but until you see it in black and white on 20 April 1 you won't know for sure. 21 MR. ABEL: If there are settled 22 reimbursement changes at the time that we're 23 reviewing your application, you know, we can 24 sensitize your budget ourselves. I think you 25 need to be able to project out what your costs ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 76 1 are, given what you know them to be now, and 2 reimbursement the same way. 3 MS. SULLIVAN: Jennifer Sullivan. 4 I'm just thinking again more about, say you're 5 scoping a project and trying to figure out what 6 it's, you know, going to be, the definition of 7 the programs in this capital project. And, you 8 know, say you have a large primary care 9 component but there are other pieces that 10 relate to the needs of your community such as, 11 I don't know, say you're thinking about 12 diabetes, dialysis things like that. Where do 13 you draw the line between saying you want to 14 include this in the application or you don't 15 want to include that in the scope because 16 that's going to hurt you more than help you? 17 And that's kind of what I'm thinking now. If 18 you could provide some guidance along those 19 lines? 20 MR. LAUDATO: Again, I think, you 21 know, as folks have said up here before, I 22 think you have to make a compelling case as it 23 relates to the expansion or improvement of 24 primary care. Primary care, there isn't a neat 25 dividing line between what specialty services ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 77 1 are to be delivered. Specialty care is part of 2 primary care, but what I don't think is going 3 to be a -- what I think is clearly not 4 acceptable is to say you want to start a 5 dialysis unit, but rather we have a large 6 number of patients. They have these needs. We 7 need better coordination. We need better 8 access. There are elements that we need to 9 combine to primary care, I think would make 10 more sense in terms of a primary care proposal. 11 MR. DELKER: Anyone else? This is 12 your last chance. Oh, there is one in the back 13 there. 14 MS. CERNY: Kathy Cerny, Broome 15 County Health Department. If your diagnostic 16 and treatment center happens to be focused 17 around oral health and dental sealants and 18 whatnot, please clarify for me why that isn't 19 considered a specialty service, just oral care? 20 I mean there are many diagnostic and treatment 21 centers out there with a specialty-focused 22 approach, and can you just explain to me why a 23 dental clinic would be acceptable as a primary 24 care? 25 MR. DELKER: Well, I think what ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 78 1 you've described would be acceptable as primary 2 care; that's preventative dental care. And 3 under a diagnostic and treatment center, you 4 know, a dentist can be the operator. They can 5 be services principally by or under the 6 supervision of a dentist. This department has 7 long considered dental care a vital part of 8 primary care and certainly oral preventative 9 care, like you described, I think would be 10 eligible. I don't see it as specialty care in 11 that sense. It's certainly an identifiable 12 care within primary care. Is that sufficient? 13 I mean you would be eligible, I think. From 14 what you described very briefly would be 15 eligible for consideration for this RGA. 16 Nothing else? Finished early. Okay, 17 bear in mind if something occurs to you later, 18 you can send your questions into the Department 19 website. Oh yes. 20 If you asked a question, please leave 21 your business card with the recorder here. 22 She's over here to my right. It will help a 23 lot in preparing the transcript and get it out 24 to you that much faster. Thank you for coming. 25 ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109 C E R T I F I C A T E I, Kyle Alexy, a Shorthand Reporter and Notary Public in and for the State of New York, do hereby certify that the foregoing record taken by me is a true and accurate transcript of the same, to the best of my ability and belief. ___________________ Kyle Alexy DATE: February 9, 2008 ALEXY ASSOCIATES COURT REPORTING SERVICES, LLC (518) 798-6109