Doddridge Family Medicine

302 Columbia Street

West Union, WV 26456

August 6, 2008

To: CMS Open Door Forum

RE: Conference ID 53532968

Changes in Conditions of Participation Requirements et.al.

Proposed Rule

I respectfully submit the following comments:

I have managed a rural medical practice in Doddridge county West
Virginia since August 1994. The physician partnership had been in
practice since 1975. Over the years physicians came and went but two
physicians have dedicated their medical careers for over thirty years to
serve their patients in this area. They sacrificed, continually cutting
their personal salaries and moonlighting on weekends at hospitals near
and far to keep the clinic open. In 1994, the medical office in West
Union became an independent Rural Health Clinic and the financial burden
eased somewhat. Then the malpractice crisis hit West Virginia and
premiums skyrocketed so they sold the practice in 2001 and became
employees of United Physicians Care, Inc. The medical office was
recertified as an independent Rural Health Clinic again in 2004.
Medicare patients represent 36.13% of our patient visits, Medicaid is
20.04%, with an additional uninsured 11.9% patient visits. We provide
free medical care to patients at 200% of the federal poverty level.

Doddridge county was a geographic HPSA, then a low-income economic HPSA
and now will be dedesignated as a HPSA in October 2008. In our
neighboring county to the west, a FQHC Ritchie County Primary Care was
established and has since expanded to other counties and eventually to
our town of West Union earlier this year (against our protests to HRSA
considering the area was already scheduled to be dedesignated and they
were going to subsidize more providers?). In our neighboring county to
the east, a private practice has expanded and contracted several times
over the years and is currently contracting again because of financial
instability. Our doctors and facility have been the consistent medical
providers in this rural county for over thirty years and now, primarily
because of the federal government, have a substantially increased risk
of becoming financial unstable and closing our doors.

The interpretation of the regulation that stimulated the proposed
changes to the payment system is unfair. If this change is adopted it
could cripple many independent Rural Health Clinics like ours. We do not
have a substantial commercial insurance base to offset the decrease in
revenue. Given that we have a reimbursement ceiling far less than the
FQHCs, and do not receive the base grant funds that the FQHCs receive,
Rural Health Clinics are extremely vulnerable to financial instability
and closure with these proposed changes.

The high costs of drugs (and other medical supplies) hamper our ability
to provide the necessary medical care for some of our patients. Not
always are we able to rely upon the Medicare patients' Part D coverage
nor the Medicaid drug coverage to provide for the needs of our patients,
especially those with no insurance and the charity patients. Consider
allowing the Rural Health Clinics to participate in the 340b program
that the CHCs and FQHCs do.

While health, safety and quality care are of supreme importance in
healthcare delivery, to require that independent Rural Health Clinics
develop, implement and maintain a QAPI program will result in increased
costs without increased reimbursement (the favorite "unfunded mandate!).
Provider based RHCs are subject to JCAHO accreditation and already have
many programs already in place as well as increased reimbursement, but
combining this additional expense to the independent RHC with the
decrease in payments is adding insult to injury.

Again with the patient health record standard, the proposed rule is
insensitive to the independent Rural Health Clinic that does not always
have the electronic medical record that can more easily date, time and
authenticate the medical record within 48 hours. These systems are found
within the provider-based RHCs. The 'requirements and guidelines'
referred to in this particular rule are irrelevant to the independent
Rural Health Clinic when referring to a 48 hour timeframe. Yes, all
records must be legible, complete, dated and authenticated, but timed
and within 48 hours is irrelevant and unrealistic.

In some ways I believe this proposed rule is 'getting the cart before
the horse.' For years we have been lobbying for an increase in the
ceiling for Rural Health Clinics and to decrease the disparity between
the FQHC and RHC payments. Some of these proposed changes would be
easier to adopt and understand if Rural Health Clinics could qualify for
additional funding from HRSA to purchase electronic medical record
systems, or to reduce expenses, be able to participate in the 340b
program and authorize RHC health professionals to be covered under the
Federal Tort Claims Act.

Rural Health Clinics have delivered cost-effective, quality healthcare
to millions of rural residents. Quality should never be sacrificed, and
it always comes at a cost but please do not interpret regulations
regarding payments with such a narrow perspective. Be sensitive to the
independent Rural Health Clinic delivery system when determining quality
performance and medical record standards.

Sincerely,

Barbara Knight, CPA

Office Manager