Rural Health Briefing, May 6, 2003

1.     Update:  Rural Hospital Flexibility Program
              a.        Arizona Flex Program Website
              b.        State Action
                         - Critical Access Hospital Designations
                         - Medicaid Fund for Critical Access Hospitals
                         - Rural Access to Emergency Devices Grant
                         - Rural Health Outreach Grant Award
                         - Events Calendar
                         - Arizona Rural Health Association Action 
              c.        National Action 
                         - Health Care Access and Rural Equity Act of 2003
                         - Community Hospital Assistance Act
   2.      Arizona News
             a.         2004 State Budget
             b.         American Indian Training Institute
             c.         Oral Health Report Card
    3.      National News
             a.         2004 Congressional Budget
             b.         NRHA Newsletter for State Rural Health Associations
             c.         National Call to Action for Oral Health
             d.         National Minority Cancer Awareness
             e.         Rural Map Book Online
             f.          Indiana Medicaid Prescription Drug Benefit
             g.         DOT Preliminary Estimates of 2002 Highway Injuries Fatalities
             h.         CDC Guidance on Use of Respirators to Prevent Transmission of SARS
             i.          Operations Manual for Hispanic Community-Based Organizations
             j.          Agency for Healthcare Research and Quality News
             k.         Rural Guide to Assist with Connectivity
             l.          Defining the Challenge of Broadband in Rural Communities
             m.        Kaiser Foundation's National Survey of Physicians
    4.     How to Contact Your Representatives
              a.         Arizona Congressional Delegation
              b.         Arizona State Legislators
     5.      Grant Opportunities
              a.         Rural Assistance Center Funding Announcements
              b.         Selected Opportunities
    6.      Conferences Relevant to Rural Health
    
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          1.        Update:   Rural Hospital Flexibility Program

           a.        Arizona Flex Program Website: The Rural Health Briefing E-Newsletters, both current and archived issues, are available through the Arizona Flex Program website for those who may have difficulty with the electronic transmission.  Arizona Flex Program   Some of the links in the newsletter may be to files that were provided to us, rather than online sites; if you have trouble opening the links, please go the newsletter link on the Flex Program website.  If it is not yet posted on the website, please check back the next day.  E-Newsletter

           b.       State Action: 

                     (1)   Critical Access Hospital Designations:  Sage Memorial Hospital's critical access designation became effective on December 1, 2002.  The Ft. Yuma IHS Hospital was designated as a California critical access hospital by the Center for Medicare and Medicaid (CMS), with a California billing number issued effective November 20, 2002.  On March 24, the Region IX Representative of CMS met with the Ft. Yuma hospital administration to confirm a change in this designation and effective April 1, 2003, the designation was switched from California to Arizona, with a new Arizona billing number issued. 

                   (2)   Medicaid Fund for CAHs:   Medicaid funds for critical access hospitals were retained in the FY 2003 state budget ($591,000 state funds matched by $1.1 federal funds).  At the present time, it appears that these funds are also included in the proposed FY 2004 budget (see more about state budget below).

                  (3)    Rural Access to Emergency Devices Grant:   The Arizona Department of Health Services has submitted an application to the Federal Office of Rural Health Policy for an RAED grant to fund purchase of automated external defibrillators for rural EMS providers and to providing training in their use and maintenance.

                 (4)    Mt. Graham Hospital Awarded Rural Health Outreach Grant:   The 2003 Rural Health Network Development and Rural Health Outreach grant awards were announced on May 1.  Mt. Graham Regional Medical Center in Safford received an award of $199,713.

                 (5)   EVENTS CALENDAR:  REMINDERS!
 

• CMS Special Ambulance Open Door Forum:   On Wednesday, May 7, the Centers for Medicare and Medicaid Services (CMS) will host an Open Door Forum that will focus exclusively on ambulance issues.  Start time is 3:30 p.m. Eastern Standard Time (EST).  Call-in-Number:  1-800-837-1935; Conference ID:  9957269. 

• CMS Provider Readiness HIPAA Workshop:  The Center for Medicare and Medicaid Services (CMS) will host a HIPAA training in Phoenix on May 8.   Further information about the HIPAA training is posted on the Flex Program website. Events CMS is also conducting HIPAA Roundtables for IHS and tribal providers on May 8, and 11 via conference calls at 10:30 a.m. Pacific Standard Time.

• Bioterrorism Grant Funds:   The Arizona Department of Health Services has received approval from the Health Resources and Services Administration (HRS) for distribution of the 2002 Bioterrorism Hospital Preparedness Program funds.  Each hospital that participated in the bioterrorism needs assessment will receive $5,000.  In addition, $1,450,000 will be distributed according to each hospital's Emergency Department volume data for the period of July 1, 2002 through December 31, 2002.  To distribute the funds, ADHS must receive an invoice on the hospital letterhead by May 15.  For further information, contact Jane Wixted, Hospital Preparedness Coordinator, ADHS (602) 364-2471.

• IHS-CSAT Training on Office Based Opioid Treatment:   A course for physicians will be offered in Phoenix on May 16 for physicians on the administration of Buprenorphine for treatment of addicted patients.  The course is sponsored by the Indian Health Service, Office of Clinical and Preventive Services, Division of Behavioral Health; the Center for Substance Abuse Treatment (CSAT) of the Substance Abuse and Mental Health Services Administration (SAMHSA), and the American Osteopathic Academy of Addiction Medicine.  The program is also accredited for CME.  Please forward this information to rural physicians that may be interested.  For further information, please contact:   Dr. Anthony Dekker or         Dr. Babak Nayeri.    Federal Invitation        Phoenix Agenda and Objectives        Registration 

• Western Region Flex Conference - Mark Your Calendar:   Arizona's Rural Hospital Flexibility Program will host a western states regional conference May 28-30 at the Embassy Suites Resort in Phoenix. Hotel reservations must be made by Wednesday, May 7 to assure the conference rate of $59. The conference program brochure is now available online. Events   For further information, please contact:  Joyce Hospodar

• Collaborative Model for Quality Improvement - Mark Your Calendar:   The Health Services Advisory Group, Inc., Arizona's Quality Improvement Organization (QIO), in collaboration with the Arizona Flex Program, will conduct a one and one-half day interactive learning session June 2-3 at the HSAG Conference Center in Phoenix for critical access hospitals and other rural hospitals.  Staff of critical access hospitals are eligible for reimbursement of expenses to participate in the workshop (see workshop brochure for details).  Events  For further information, please contact:  Joyce Hospodar

• Arizona EMS Conference - Rural Health Track - Mark Your Calendar:   The Arizona Emergency Medical Systems, Inc. (AEMS) 3rd Annual EMS Conference is scheduled June 19-20 at the Embassy Suites Resort in Phoenix.  Hotel reservations must be made by May 16 to assure the conference rate.  The Rural Health Track, developed in collaboration with the Arizona Flex Program includes the following concurrent sessions scheduled on June 19: (1)  National Trends in EMS:  Evan Mayfield, MS, Federal Office of Rural Heath Policy (10:00 - 11:00).   (2)  Where the Rubber Hits the Road -- Current Issues in Rural EMS:  Bill White, Fire Chief, I-EMT, Ak-Chin indian Community; Jim Flaherty, MD, Medical Director of EMS for Navajo Area IHS, Emergency and Pediatric Departments, Tuba Indian Medical Center; Judi Crume, Chief, ADHS Bureau of Emergency Medical Services; Toni Brophy, MD, FACEP, Medical Director, Mesa Fire Department; Jeff Mercado, CEP, Assistant Director for Gila River EMS; Tina Tessay, CEP, Training Coordinator and Assistant Director, White Mountain Apache Tribal EMS (Noon - 1:15).    (3)  Get Out the Scalpel -- Shaping a Rural EMS Agenda for the Future:  Open participant discussion (1:30-2:30).  A copy of the AEMS Conference brochure is available on the Flex website,  Events   For further information, please contact:     Sonya Roberts

           (6) AzRHA Board Action:   On April 29, the Board of the Arizona Rural Health Association wrote to members of the Arizona congressional delegation urging their support for passage of  the Health Care Access and Rural Equity Act and the Rural Community Hospital Assistance Act.  A number of provisions in these bills provide are applicable to critical access and other small rural hospitals.  Details are described in the next section. 

         c.       National Action:

                  (1)   Health Care Access and Rural Equity Act of 2003:   On April 8, Senator Kent Conrad (D-ND) and Senator Craig Thomas (R-WY) introduced S. 816 to provide for improvements in access to services in rural hospitals and critical access hospitals.  Congressmen Jerry Moran (R-KS) and Earl Pomery (D-ND) introduced companion bill, H.R.937.  Referred to as H-CARE, the legislation includes the following provisions:
 

• Eliminate the "35 mile isolation test" for critical access hospitals to be cost-reimbursed for ambulance service
• Allow critical access hospitals to determine what portion of their 25 beds are acute care inpatient beds and what portion are swing beds
• Extend reimbursement to nurses, physician assistants, and clinical nurse specialists who are on-call for emergency care at critical access hospitals
• Reinstate Periodic Interim Payments for critical access hospitals
• Create a Capital Infrastructure Loan Program to provide $5 million in loans to rural facilities for improvements in buildings and infrastructure and provide for $50,000 planning grants to help assess capital and infrastructure needs, authorized through September 30, 2008
• Exclude critical access hospitals from the wage index calculation of the hospital wage index for those facilities receiving PPS -- (inclusion artificially brings down the wage index calculation for other rural providers that are receiving PPS)
• Allow independent labs to continue receiving reimbursement directly from Medicare, reducing burden on small rural facilities to begin reimbursing them directly, as required by a change in CMS regulations
• Make permanent standardized Medicare inpatient payments, eliminating 1.6 higher payments for hospitals located in cities serving a population of more than 1 million
• Remove cap on rural providers for Medicare Disproportionate Share Payments, bringing their payments in line with benefits urban facilities receive
• Providing a new low-volume adjustment payment for small rural hospitals that serve a low volume of patients, decreasing as the level of inpatient admissions rise and phasing out completely for facilities that discharge more than 2,000 patients per year
• Reduce the labor share percentage adjusted by the wage index to 62 percent, increasing inpatient reimbursement for many rural hospitals; hospitals that would be harmed by this change would be held harmless
• Direct Secretary of Health to develop rules that would allow hospitals located in sparsely populated areas (states with fewer than 20 people per square mile) to re-classify their wage index without meeting the current county proximity/adjacency requirements
• Extend the hold harmless from PPS for rural hospitals with less than 100 beds to January 1, 2005 and allow sole community hospitals with more than 100 beds to be eligible for for the outpatient hold harmless until January 1, 2005
• Five year reauthorization of Rural Hospital Flexibility Program, and increase funding from $25 million/year to $40 million/year
•  

                     (2)  Community Hospital Assistance Act:

2.       Arizona News

        a.        2004 State Budget:  The Joint Legislative Budget Committee issued a revised budget proposal for FY 2004 on April 22.  The JLBC's initial budget proposal was $6.09 billion; the revised budget proposal is $6.18, based on projected increases in revenue.  The Governor's budget proposal is $6.62 billion.  A comparison of the JLBC proposed budget and the Govenor's proposed budget is now available on the Governor's website: Budgets Comparison   The Arizona Rural Health Association forwarded a reader-friendly abbreviated comparison and a list of copay requirements proposed for KidsCare and other AHCCCS enrollees.  Reader Comparison   Copay Requirements Some issues of concern about the JLBC proposed budget include:  (1)  new cost-sharing proposal for KidsCare and other AHCCCS patients which reduces providers' capitation and requires them to collect co-payments to make up the difference; (2)  elimination of coverage for KidsCare parents, which brings in $77.8 million in federal revenue; (3)  reduction in AHCCCS coverage period from 12 months to six months, requiring patients to re-enroll every six months; (4)  cuts in ADES eligibility who process AHCCCS applications; (5)  prohibiting media advertising for KidsCare, to increase enrollment of eligible children; (6)  lack of funding for prenatal and perinatal programs and Premium Sharing health coverage.

           b.        American Indian Training Institute: On May 18-23, the Substance Abuse and Mental Health Services Agency (SAMHSA) will hold a grantwriting and capacity building workshop for American Indians, Alaskan, and Hawaiian nationals in Tucson, Arizona.  For more information, contact Dave Vallo (916) 920-0731 or Clifton Mitchell (301 443-8804.

           c.       Oral Health Report:  Oral Health America has issued a 2003 state-by-state report card.  Arizona is given an overall grade of C+, compared to the overall grade for the United States of C.  Grades are given in a variety of categories:  (1)  Access (% of counties without Medicaid provider; Medicaid dental providers; significant Medicaid providers; dental insurance status of the elderly); (2)  Infrastructure (dental director; oral health plan; oral health coalition; plan/input); (3)  Budget (budget size; budget change; state support for oral health budget); (4) Data Use (data use - sealants; data use -- untreated caries; data use -- caries experience; data use -- recency of dental visits; data use -- fluoridation); (5)  Health Status (adults with six or more removed teeth due to decay/disease; edentulous elderly; youth tobacco use; change in oral cancer mortality rates). 
Oral Health Report Card

         3.      National News

        a.      2004 Congressional Budget:  For a review of the FY 2004 congressional budget resolution, see: Budget Resolution

        b.    NRHA Newsletter for State Rural Health Associations:   The National Rural Health Association now distributes a newsletter for state associations, Council Update.  The NRHA's Journal of Rural Health is also now available online.  Articles of interest in the Spring 2003 issue include: Variations in Nursing Home discharge Rates for Urban and Rural Facility Residents With Hip Fracture;  Characteristics of Rural Elderly People Who Bypass Local Pharmacies; The Experience of Native Peer Facilitators in the Campaign Against Type 2 Diabetes; Small Town Health Care Safety Nets:  Report on a Pilot Study; and Impact of Conversion to Critical Access Hospital Status for Oklahoma's Rural Hospitals. Journal of Rural Health The NRHA has issued a call for manuscripts for a supplemental issue of the journal on Rural Minority and Multicultural Preventive Care, Primary Care and Mental Health Issues -- Challenges and Opportunities. Featured manuscripts will cover preventive care, primary care, mental health, and women's issues as they relate to these communities.  The goal is to assist providers, professionals, educators and others in eliminating health disparities in rural racial and ethnic minority and multicultural communities.  Deadline for submission of manuscripts is September 30, 2003.  All manuscripts will be peer-reviewed and should follow AMA style guidelines.  For further information, contact: NRHA Minority Affairs Liaison and Program Services Manager, Rosemary McKenzie at (816) 756-3140.

          c.      National Call to Action for Oral Health:   The Surgeon General has issued a call to action for oral health that includes addressing the needs of rural residents.  To review the document, see:  National Call

         d.     National Minority Cancer Awareness:   HHS Secretary Tommy Thompson recently announced several initiatives to address the health care needs of minorities related to cancer.  One of these is a new CDC website that provides a portal to cancer resources.
 Cancer Control Planet

         e.      Rural Map Book Online:  The North Carolina Rural Health Research and Policy Analysis Center reports that the map book on "rural populations and health care providers" is on their website at:  Rural Map

         f.      Indiana Medicaid Prescription Drug Benefit:  In April, HHS Secretary Tommy G. Thompson announced approval of an Indiana program that will provide access to Medicaid prescription drug benefits for low-income seniors.  Indiana officials estimate that eventually more than 44,000 low-income seniors will be aided under the HooserRx program -- roughly triple the number now being served under the state's existing pharmacy program.  Indiana's program will serve persons with incomes up to 135 percent of the federal poverty level.  The co-payment system will be on a sliding scale based on the person's income with annual benefit caps ranging between $500 and $1,000.  To date, HHS has approved Pharmacy Plus programs in six states -- Florida, Illinois, Indiana, Maryland, South Carolina, and Wisconsin.

         g.      DOT Preliminary Estimates of 2002 Highway Injuries Fatalities:  The National Center for Statistics & Analysis of the National Highway Traffic Safety Administration issued a 2002 Early Assessment of Motor Vehicle Crashes in April.  Major Findings:  (1)  number of persons killed increased to the highest level since 1990; (2)  injuries declined; (3)  fatality rate was unchanged; (4) injury rates declined; (5) occupant fatalities accounted for all of the increase in total fatalities; (6) non-occupant fatalities declined; (7) most passenger vehicle occupant fatalities continue to be unrestrained; (8) alcohol-related fatalities increased; (9) increase in alcohol-related fatalities was concentrated in occupants of vans and SUVs and riders of motorcycles; (10) SUVs, vans, and motorcycles had a larger increase in alcohol-involved drivers than other vehicles; (11) passenger vehicle occupant fatalities in rollover crashes increased; (12) fatality increases in SUV and pickup rollovers accounted for nearly half of the increase in total occupant fatalities; most of the increase in passenger vehicle fatalities; (13)  passenger car occupant fatalities in two-vehicle crashes with a pickup truck, van, or SUV increased; (14) motorcyclist fatalities continued to increase; (15) fatalities of older motorcyclists increased while fatalities of younger motorcyclists declined; (16) fatalities for children ages 0-3 and ages 4-7 declined;  (17)  fatalities for occupants ages 8-15 increased; (18) fatalities of young drivers (ages 16-20) increased. DOT Report

         h.      CDC Guidance on Use of Respirators to Prevent Transmission of SARS: The CDC recently released information on the selection and handling of respirators for SARS and includes guidance for when respirators are either not available or in short supply:   Respirators and SARS

         i.       Operations Manual for Hispanic Community-Based Organizations:  The Environmental Protection Agency maintains a website for community-based approaches to environmental issues that may offer a model for health-related issues as well.  Publications of interest include an Operations Manual for Hispanic Community-Based Organizations, Community Culture and the Environment: A Guide to Understanding a Sense of Place; Connecting Environmental Issues with Citizens' Spiritual and Religious Beliefs; This Place Called Home: Tools for Sustainable Communities; Principles for Effective Communication With Communities About Ecological Issues.  Community-Based Approaches Operations Manual 

        j.      Agency for Healthcare Research and Quality News:

               (1)    Your Medicine:  Play It Safe:  AHRQ recently published a 12 page brochure, available in English and Spanish, that includes a detachable, pocket-sized medicine record form that can be personalized for consumers.   English      Spanish

               (2)     New Evidence Report Summary on Health Care Working Conditions:   This new report includes recommendations on specific strategies for improving patient safety.  Future patient safety research projects will focus on issues addressed in the report. Working Conditions

               (3)     National Women's Check-Up Day is May 12:   HHS is coordinating the first ever National Women's Check-Up Day on May 12 as part of National Women's Health Week.  Community health centers, hospitals, and other health providers are asked to encourage women to come in for preventive health services.   Women's Check-Up Day

              (4)     Take a Loved One to the Doctor Day is September 16:  Take a Loved One to the Doctor Day is part of a national campaign that aims to close the health gap between the health of communities of color and the general population.  By encouraging individuals to visit a health care professional or make an appointment to do so on or near September 16, HHS hopes t generate a greater understanding of the importance of regular health screenings.   Loved One Doctor Day

              (5)     Immunization and the Prevention of Influenza and Pneumococcal Disease in People with Diabetes:   An update of a previously published guideline summary is available through the National Guideline Clearinghouse.   Flu and Pneumonia in Diabetes Patients

             (6)     Emergency Department Satisfaction Surveys:    The follow survey information was reported by the National Quality Measures Clearinghouse newsletter.  The following links are for different sections of an emergency department survey.   Arrival    Doctors   Family or Friends       Nurses   Overall Assessment       Personal Issues      Personal/Insurance Information        Tests

       k.     Rural Guide to Assist with Connectivity:   The National Center for Small Communities has published a new guide to assist small communities, Getting Online 2.0.  For more information:   Small Communities Rural Guide

       l.      Defining the Challenge of Broadband in Rural Communities:   A January 2003 report of the Rural Policy Research Institute (RUPRI) is now available online:  Broadband

       m.      Kaiser Foundation's National Survey of  Physicians:   The biennial survey found that most physicians (87%) say the overall morale of physicians has decreased in the last five years.  About six in ten say their own enthusiasm for practicing medicine has lessened over the same time period.  Most doctors are satisfied with the continuity of their relationships with the patients (84%), professional challenges (79%), and current incomes (57%), but they are dissatisfied with the amount of work hours spent on administration compared with patient care (74%), the time they have for nonprofessional interests, family, and friends( 56%), autonomy in clinical decisions (54%), and their future income prospects (53%).  Four in 10 physicians say they would not recommend the practice of medicine to a young person today.  The majority (76%) say that managed care has at least somewhat negatively affected the way they practice medicine -- and doctors are more likely now than they were in 1999 to believe this strongly (41% vs. 25% in 1999).  Doctors do believe managed care has had a positive effect on the use of practice guidelines and preventive care. 
Physician Survey

4.        How to Contact Your Representatives

          a.      Arizona Congressional Delegation:  Links to Arizona members of the U.S. House of Representatives are available at:   U.S. Representatives   Links to Arizona members of the U.S. Senate are available at:  U.S. Senate

          b.      Arizona State Legislators: Available through the Arizona Legislative Information System (ALIS): Call 1-800-352-8404   Arizona Legislature

         5.       Grant Opportunities:

                   a.      Rural Assistance Center Funding Announcements: RAC Funding

                   b.      Selected Opportunities:
 

                   (1)       SAMHSA:  Prevention of Meth and Inhalant Abuse in Rural Areas:  Due May 23, 2003.   Rural Substance Use Prevention

                  (2)     Universal Services Telecommunications Discount: Applications are due May 30, 2003 for rural not-for-profit health care providers to receive telecommunications services necessary for the provision of health care at reduced rates.  For more information, call the Rural Health Care Division, Universal Services Assistance Corporation at 1-800-229-5476. 
Website:   RHCD/USAC Application Program Brochure

                (3)     Childhood Agricultural Safety and Health Research Grants:  The purpose of this program is to provide support for a National Center for the Prevention of Childhood Agricultural Injury.   Approximately $1,000,000 is available in FY 2003 to fund four to six awards.  Letters of Intent are due May 20, 2003.  Application is due June 12, 2003.  Funded by the CDC and the National Institute for Occupational Safety and Health (NIOSH).  Childhood Safety

                (4)      AHRQ:   Patient Safety Practices Challenge Grants:   Due July 15, 2003.  AHRQ is seeking applications from hospitals and other health care organizations to study and implement patient safety practices.  AHRQ will fund up to half of the total cost of the projects, with grant recipients funding the other half.  It will award grants of up to $200,000 for up to 12 months to projects identifying risk areas, and grants of up to $500,000 per year for up to 24 months to projects implementing safe practices. Patient Safety Grants

               (5)      Rural Health Initiative Community Outreach Grant:   The National Rural Health Association and Multiplan are soliciting applications for grants that will allow rural hospitals to offer new services, expand existing services, or reach new populations.  Eight grants will be awarded.  Applications are due October 15, 2003.  To receive a grant, your hospital must be a member of the NRHA and must participate in MultiPlan's healthcare network. Rural Community Outreach

              (6)     Microsoft Software Donation Program:    Tech Soup, a nonprofit technology organization, offers an enhanced Mircrosoft Software Donation Program with more than 35 software titles, availability of up to 6 titles per organization, and up to 50 licenses per title.  Eligible organizations can make one donation request through DiscounTech per 2-year period.  Software Donation

             (7)      Local Initiative Funding Partners Program:   The LIFP program is a matching grants program designed to establish partnerships between the Robert Wood Johnson Foundation and local grantmakers in support of innovative, community-based projects that improve health and health care for underserved and at-risk populations.  Grants total anywhere from $100,000 to $500,000.  All awards are matching dollars and the match must come from local grantmakers.  LIFP

6.      Conferences Relevant to Rural Health

          a.       CDC Public Health Initiative on Diabetes and Womens Health:  A Call-to-Action Conference for a national agenda on diabetes and women's health is scheduled in Washington DC May 20-21.  For further information, see project website at:  Diabetes and Womens Health

          b.       9th Annual Rural Minority Health Conference:   May 23, 2003, National Rural Health Association, Salt Lake City, UT.  For more information, call (816) 756-3140 or email Rosemary McKenzie.

          c.       15th Annual IHS National Research Conference:   May 13-15, 2003.  DoubleTree Paradise Valley Resort, Scottsdale, Arizona.  Call (301) 443-1492 or email Oire Platero.

          d.       NRHA's 26th Annual Rural Health Conference:   May 14-17, 2003.  Salt Lake City, UT.  Call (816) 756-3140 or email Kathy Siress.

         e.        CMS Rural Health Open Door Forum:  May 16, 2003, 2:00 pm.  Nationwide conference call.  Call (410) 786-9176 and speak to Alikia Brown or Teresa Mundell for further information.

         f.        National Farmworker Alliance Advocacy Conference:  May 18-21, 2003.  Washington DC.  Call (320) 650-1711 or email  Heladio Zavala.

         g.        Focusing on Front Desk Collections:    May 21, 2003.  Health Resources and Services Administration, web-assisted audio conference.   Call (866) 877-8439.