1. Sample Board Presentation Sandy Champion, CMSR The Champion Group, LLC A Compelling Case for Community Needs Analysis… Forecasting Physician Supply/Demand

2. The Champion Group, LLC2 Community Needs Analysis Physician Supply/Demand In-depth analysis of a given service area to determine the appropriate estimated number of physicians required to provide adequate medical coverage now and in the future For Hospitals and medical groups From the community need point of view Redefining your service area Forecasting physician supply/demand

3. The Champion Group, LLC3 Why Conduct a Community Needs Physician Supply/Demand Analysis? Legal Compliance Understand Access to Care Economic Success

4. The Champion Group, LLC4 Legal – Regulatory Compliance Applies to all tax exempt hospitals under the Internal Revenue Code §501(c)(3), Anti-kickback statute, and the Stark Law Applies to all hospitals that are tax-exempt as public entities or municipal corporations (e.g. public hospital districts) Some application to all hospitals participating in federal payment programs (Medicare and Medicaid) that engage in physician recruiting activities.

5. The Champion Group, LLC5 Legal -- IRS In an attempt to balance two competing needs by permitting recruiting incentives an basis that a hospital establishes a “community need” IRS and OIG DHHS required tax-exempt hospitals to demonstrate evidence of a community need for the recruited physician. IRS Rev. Ruling 97-21 (April 1997) addresses implications of physician recruitment arrangements and emphasis based on demonstrated community need. Strongly suggests that demonstrated community need is an important factor finding recruitment permissible. Hermann Hospital Closing Agreement (1994) detailed recruitment guidelines. States “permissible incentives” will not be considered unless demonstrated community need evidenced by: specialty deficit, lack of availability, demonstrated reluctance to relocate, long waiting periods, Federal HPSA Designation, reasonable decrease due to retire, deficit serving Medicaid.

6. The Champion Group, LLC6 Legal -- IRS Unpublished Private Letter Ruling (1998) Maintained importance of demonstrated objective evidence of need for the physician in the form of needs assessment. IRS Rev. Ruling 73-313 (1973) concluded that when a hospital conducted “community needs assessment demonstrating need they provided sufficient, objective evidence of need.” IRS Hospital Audit Guidelines (1992) Hospital examination guidelines for compliance with community benefit standard required for 501(c) (3) refer to need for physician in the community must be determined Note: This exhibit is not a complete discourse on the law in this area and is not intended as legal advice. Specific situations require specific analysis and advice by a qualified attorney.

7. The Champion Group, LLC7 Legal – “OIG” (DHHS) Federal Medicare Anti-kickback statute enforcement agency “OIG” applies all hospitals OIG Advisory Opinion (2001) Concern in offering recruitment incentives. Offer safe harbors with documented evidence of objective community need. Less suspect for HPSA or recruited physician’s services. OIG Fraud and Abuse Compliance Program Guidelines (1998) For hospital recruitment to identify fraud and abuse issues that could pose significant risk. Recommends that hospital’s provide evidence “that recruited physicians’ specialty is necessary.”

8. The Champion Group, LLC8 Legal – CMS (Stark) Stark Law Phase I (1989) Phase II (2004) interpreted by CMS determined recruitment as part of “financial relationship” and silent on community need as a factor in finding exception to the prohibition against physician referrals. It is expected that by 2008 Stark will include community need as documentation for a recruiting exception.

9. The Champion Group, LLC9 Understand Access to care Clarifying FTEs Open,limited,closed practices (by insurance by specialty) Wait times Use of midlevels Succession needs Baby-boomer population Physician distribution, growth potential Population segments with limited or timely access Service gaps

10. The Champion Group, LLC10 Economic Physician Supply = economic expansion Organizational success Ideal/adequate manpower Growth potential Attractive to candidates Market share

11. The Champion Group, LLC11 What is Community Need Physician Supply Analysis and Planning? “ A required statistical document to comply with all government regulations, guidelines, and recommendations.”

12. The Champion Group, LLC12 Analysis Quantitative Analysis (statistical) Current supply providers database Service area assessment Physician-to-population comparison Qualitative Analysis (narrative) Practice access analysis Market-driven factors Succession

13. The Champion Group, LLC13 Who are the Stakeholders?

14. The Champion Group, LLC14 Methodology – Service Area Definitions 1. Primary Service Area (“PSA”): Includes those zip codes from which the hospital derives approximately 85%-90% inpatients. 2. Secondary Service Area (“SSA”): Includes those zip codes from which the remaining inpatient discharges come from. 3. Stark Definition of geographic area where recruited physicians must relocate: “The area composed of the lowest number of contiguous zip codes from which the hospital draws at least 75 percent of its inpatients.” (CMS Stark II Phase II July, 2004)

15. The Champion Group, LLC15 Methodology -- Ratios Baseline G.M.E.N.A.C. 1990 C.O.G.M.E. American Medical Association Market-Driven Solucient Other published reports

16. The Champion Group, LLC16 Methodology – Data Collection 1. Service area definition/overview 2. Internal assessment 3. Physician workforce database including physicians and midlevels 4. Access study 5. Physician supply/demand analysis

17. The Champion Group, LLC17 Final Analysis Report and Electronic Desktop Supply Database Demand Analysis Succession Analysis Provider Database Demographics Population Market share Recommendations

18. The Champion Group, LLC18 Challenges…Final Thoughts Challenges: Given a statistical need, what is the strategic need based on the key issues? Then, how to design a delivery system to match capacity against demand while accommodating the underserved populations but not damaging the private practice providers who are serving their patients How to proceed with a comprehensive hospital program that is well designed, meets the community needs, and is well-communicated throughout the medical community Final Thoughts: Most hospitals are likely to experience moderate to significant shortages in various specialties Develop a system to analyze and track workforce supply, physician distribution, succession, and demand needs with relevant tools can assist hospitals to assure access to care and success for decades to come.

19. The Champion Group, LLC19 Contact Sandy Champion, CMSR The Champion Group, LLC (206) 567-7737 Main (206) 658-5113 Cell (206) 567-0516 Fax championgroup42@msn.com www.thechampiongroup.org