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Libby Community Advisory Group
Meeting Summary

October 9, 2003
Introductions

Gerald Mueller and members of the Libby Community Advisory Group (CAG) introduced themselves. A list of the members and visitors in attendance is attached below as Appendix 1.

Agenda

The CAG agreed to the following agenda for this meeting:

ATSDR Report

Dan Strausbaugh, who was unable to attend this meeting, emailed a letter to Gerald Mueller and asked that it be read at the meeting. The letter announced that Mr. Strausbaugh will no longer to attending CAG meetings on a regular basis. Mr. Mueller read the letter aloud.

EPA Report

Jim Christiansen presented a humorous retrospective on EPA's work in Libby using a Power Point presentation.

Wendy Thomi announced that the documentary "Dust to Dust" which is about asbestos and Libby will air on KSPS, the Spokane pubic television station, on October 21. The program has already aired on the Montana public television station which covers the state except for Libby.

W.R. Grace Medical Plan Letter

David Latham read the letter which he drafted at the request of the CAG at its September 11 meeting. A copy of the letter is included in Appendix 3.

Audience Member Question - Can the hospital accept the payment made by the W.R. Grace Medical Plan as the full payment?
Answer by Rick Palagi - St. John's Lutheran Hospital (SJLH) can establish a contract with W.R. Grace that would agree on prices for services. Legally, we cannot merely ignore a underpayment by the W.R. Grace Medical Plan. If, for example, we normally charge $690 for a CT Scan and the W.R. Grace Medical Plan pays only $650 dollars, we must by law bill the patient for the remaining $40.

Audience Member Comment - In my job with the CARD Clinic, I work with the W.R. Grace Medical Plan to get the full patient bill paid by the plan. I would support including in the CAG's letter language requesting that W.R. Grace pay 100% of usual and customary charges.

CAG Member Comment - The W.R. Grace Medical Plan administrator, Health Networks of America, pays only what it says is reasonable and customary. The remainder of the bill is the patient's responsibility.

CAG Member Comment - The problem is that the W.R. Grace Medical Plan is not a regular insurance plan. The W.R. Grace Medical Plan is a response to their liability. W.R. Grace promised to pay 100% of asbestos-related medical costs, and it should do so.

Audience Member Comment - One has a choice to enter an insurance plan. Many people in Libby do not have no other choice but the W.R. Grace plan. There should be no cost shifting by W.R. Grace either to patients or the hospital.

Audience Member Question - If W.R. Grace pays 100%, what would stop medical providers from raising their prices?
Answer - Hospitals and clinics cannot raise the price for some patients and medical plans and not for others.

Audience Member Question - Did a price increase at the hospital cause W.R. Grace to pay only 80%?
Answer - No. The hospital's objective is not to bill asbestos patients. Our charges are competitive with the hospitals in our area. Insurance companies are in business to make a profit so they negotiate price schedules with hospitals. We have negotiated schedules with providers such as Blue Cross/Blue Shield. Perhaps the letter should request that W.R. Grace pay 100% of what Blue Cross/Blue Shield allows.

CAG Member Question - When I get medical bills there are two charges. Some are negotiated amounts between my insurance provider and the hospital. Some are the 80-20% split. Why not ask W.R. Grace to negotiate fees with the hospital?

CAG Member Comment - I can understand why the hospital would not want to negotiate with W.R. Grace. It is an insult for us to have to engage in this conversation. In its plan, W.R. Grace controls what is asbestos-related disease.

Audience Member Comment - The pharmacies at ShopCo and Rosauers have had to negotiate with W.R. Grace.

Audience Member Comment - W.R. Grace is not an insurance company like Blue Cross/Blue Shield. If the W.R. Grace Medical Plan negotiates a deal with a Kalispell hospital, you could be forced to travel there for treatment.

CAG Member Comment - W.R. Grace did try to negotiate such a deal. They want to pay as little as possible. The letter should not include language about negotiating. It should request 100% payment.

CAG Member Comment - W.R. Grace promised 100% payment. The documentation requirements keep getting harder. The Medical Plan is changing creating greater obstacles for people to get care.

CAG Action - After the discussion and public comment, the CAG unanimously decided to send the letter as drafted by Mr. Latham with the following change:

Replace the last sentence in the second paragraph with, "In the unlikely event that fraudulent or unreasonable claims are made by doctors or hospitals, then W.R. Grace & Company should pursue whatever avenues are needed to resolve the situation without burdening the victims."

The CAG members present then signed the signature page, and Mr. Mueller was directed to make the noted change and mail the letter.

Tobacco Education Forum

Barb Guthneck, Executive Director Libby Community Interagencies, Inc., reported that grants are available from the state to four counties for tobacco education. Lincoln County intends to apply for funds to hold a forum on the effects of second hand smoke. Because of the asbestos disease here, Lincoln County's application will have a good chance to receive funding. Ms. Guthneck asked the CAG to send a letter of support for the grant.

CAG Member Question - Would the grant support only educational activities? Would it also fund medicine to help people quit?
Answer - The money comes from tobacco settlement dollars and can not be used for smoking cessation. It must be used for education.

Audience Member Question - I was able to stop smoking through hypnosis. Could we bring in a hypnotist?
Answer - The Center for Disease Control says that cold turkey is the best way to quit, but maybe we could seek other funding to do so.

CAG Member Question - What would be the CAG role in the forum?
Answer - Because this group is well known and respected in the community, we hope that you would be a sponsor of the forum.

CAG Action - The CAG agreed unanimously to Ms. Guthneck's request that it support the grant request. A letter was passed around for member signatures.

Community Health Center Report

Kimberly Rowse, a registered nurse and director of the Community Health Center (CHC) reported on behalf of the CHC. The CHC provides primary medical care to people in Lincoln County. No one is turned away. Charges are set on a sliding scale based on income and family size. People with incomes at or below 200% of federal poverty guidelines are charged only $5 per visit. Some 26% of our patients pay only the $5 charge, and 38% pay on a sliding scale. Laboratory and radiological treatment is supplied through the CHC at SJLH on a sliding fee basis. As of the first of this month, CHC is also offering a pharmacy program in conjunction with Frank's Pharmacy. Patients who qualify receive a substantial discount on medications, from 7-65%. With the assistance of the Kalispell Medical Center, SJLH, and the CARD Clinic, the CHC was able to bring in a second doctor, Dr. Peters. The CHC also has a partnership with the Libby School District to provide a medical clinic one half day per month at both the middle school and high school to provide medical services to children.

CAG Member Question - In her letter declining to declare a public health emergency in Libby, the head of the CDC Dr. Gerberding cited the grant to the CHC as one way the federal government is meeting Libby's health needs. How many people diagnosed with asbestos-related disease are being treated at the CHC?
Answer - I don't know, but I will find out.

Audience Member Question - How many people are entering the health care system because of asbestos-related disease?
Answer - The CHC provides primary health care, including diagnosis, medications, and treatment. We offer specialized asbestos-related disease treatment.

Audience Member Question - Do you refer patients to the W.R. Grace Medical Plan?
Answer - One of our functions is to identify medical care resources. We refer to the W.R. Grace Medical Plan, the Libby Asbestos Medical Plan, and government insurance plans. We pass out a brochure for the W.R. Grace Medical Plan.

Audience Member Question - Are people in Libby not seeking care because of its cost?
Answer - Yes. Barriers include cost as well as people's values, such as reluctance to ask for help. The CHC is trying to get the word out that it provides medical care at no or low costs.

Audience Member Question - How many patients does the CHC see a day?
Answer - Last year the CHC saw a total of 981 people. This year to date, we have seen 1,311 people, a 34% increase.

Audience Member Question - What geographical area does the CHC serve?
Answer - Lincoln County. On October 16, we will have outreach to Eureka. For their relative size, we see the same percentage of people from Libby and Troy.

Audience Member Question - When I see people at the MASSA asbestosis screening, can I refer them to the CHC?
Answer - Yes.

CAG Member Question - If people have health insurance, you do bill their insurers?
Answer - Yes, however, 44% of our patients are uninsured.

CAG Member Question - Do you subject any deductible or co-payment amount to the sliding scale?
Answer - Yes.

CAG Member Question - I have a question for the CHC, CARD Clinic, and SJLH. Are people who lived here for at least six months prior to 1990 being turned over to collection agencies because they cannot pay their medical bills?
Answer by Kimberly Rowse - The CHC has a liberal collection policy. We try to arrange repayment schedules with our patients. If they pay at least $1 per month, we do not involve collection agencies. We write off any bill less than $25 that is over 120 days old. However, we do have to have revenue to remain viable.
Answer by Rick Palagi - I don't know. I suspect that SJLH has turned some overdue bills to a collection agency.
Answer by Pat Cohan - The CARD Clinic has only been open six months. We have not yet turned over any bills for collection. We are working to get people on the W.R. Grace Medical Plan. We also talk with our patients up front about billing.

CAG Member Comment - We need to establish that people exposed to asbestos in Libby have unmet health needs. People turned over to collection agencies face damage to their credit and denial of medical services. Please keep the CAG informed about this issue.

Audience Member Comment - People and medical providers should not carry this burden. The amount of money in 20% co-pay requirement means nothing to W.R. Grace, but it can mean bankruptcy for people here in Libby.

CAG Member Comment - Being subject to the requirements of the W.R. Grace Medical Plan is insulting, and I have opted not to do so. 

CAG Member Comment - It was pointed out to me in discussions after the last CAG meeting that W.R. Grace pays SJLH $250,000 per year, so the hospital should not have to turn asbestos-related disease patients over to collection agencies.

Public Comment

CAG Member Question - Did Dr. Black testify at a Senate hearing that five cases of mesothelioma were diagnosed in Libby over an 18 month period?
Answer by Dr. Black - I don't remember the details of my testimony. Since 1976, 23 cases of mesothelioma have been diagnosed here, close to one per year. This is 100 times the rate for this disease that would be expected for a community of this size.

CAG Member Comment - This rate of disease of mesothelioma is testament to the widespread exposure to tremolite asbestos we have suffered.

Audience Member Question - Do you have to have asbestosis to get mesothelioma?
Answer by Dr. Black - No. Asbestos exposure is the only known cause of mesothelioma, but the latter disease is associated with lower levels of exposure. It is possible to have mesothelioma without diagnosed asbestosis.

Audience Member Question - Are children more at risk for mesothelioma?
Answer by Dr. Black - I am not aware than the children are more susceptible than adults. Mesothelioma does have a long latency period, however, 30 to 40 years.

Audience Member Question - Is tremolite associated with lupus disease?
Answer by Dr. Black - I am not aware that this fiber produces different immunological responses, but research is underway.

Audience Member Comment - Nobody is listening to the concern I expressed at the last meeting. People are moving to Libby and into homes contaminated with asbestos without being told of the contamination. We need an ordinance or law or EPA to require that realtors, homeowners, and landlords tell potential home purchasers and renters of the danger.
Response by Jim Christiansen - This is a difficult issue. EPA cannot prevent people from moving to Libby. Up until a year ago, we did not know which homes are contaminated. Lenders, realtors, and landlords should provide information about contamination. The operation and maintenance work group which is being formed will be asked for advice about how to do this without affecting private property rights.

Audience Member Comment - The Technical Advisory Group has looked at property transfer agreements. Asbestos disclosure is required when homes are sold. The problem is rentals. It is within the jurisdiction of local government to pass an ordinance to require asbestos disclosure to renters.
Response by Jim Christiansen - We will ask a representative of the realtor community involved with rentals to come to the next CAG meeting to discuss this issue.

Next Meeting

The next regular CAG meeting is scheduled for 7:00 to 9:00 p.m. on Thursday, November 13, 2003 in the Ponderosa Room of Libby City Hall.

Appendix 1

CAG Member & Guest Attendance List
October 9, 2003

Members

Group/Organization Represented

Sandy Wagner

Community Health Center/TAG

George Keck

Technical Advisory Group

W.K. Maki

Libby Schools

Craig French

Montana Department of Environmental Quality

Jim Christiansen

EPA Project Manager

George Bauer

City of Libby

Leroy Thom

Former Grace Employee

David F. Latham

The Montanian Newspaper

Ken Hays

Senior Citizens

Bob Dedrick

Asbestos Victim

Clinton Maynard

Area Asbestos Research Group

Brad Black

Medical Director of the CARD Clinic

Eileen Carney

State Representative

Wendy Thomi

US EPA

Rick Palagi

SJLH

Appendix 2

October 8, 2003

Greetings,

For more than three years, it has been my pleasure to work with the residents of Libby and especially those willing to volunteer considerable time and energy to the CAG. ATSDR has been involved with the Libby Asbestos Project since November, 1999. I began attending regular CAG meetings in August, 2000. During this time, I have represented ATSDR and served as a public health advocate and resource for the Libby CAG. Earlier this summer, ATSDR published the combined medical testing results, and ATSDR public health objectives identified during the early stages of the Project have been completed. I have continued to attend regular CAG meetings, although I have not had much new information to share for the past few months. Therefore, ATSDR Management has decided that I should discontinue participating in monthly CAG meetings at this time.

ATSDR will continue to support and assist ongoing and future public health initiatives in Libby. I will continue to support the MASSA clinic and the ATSDR Tremolite Asbestos Registry and provide technical assistance to local county agencies involved with various public health and health education initiatives. I have a number of other site responsibilities in Montana and my office will remain in Helena. However, Libby will continue to be a priority site and I look forward to providing the CAG and the community with technical assistance as necessary.

In closing, I would like to say that I am thankful for the opportunity to work with you and shall miss visiting regularly with the many new friends I have had the fortune to make in Libby over the years. Through the CAG's leadership and influence, the community's list of accomplishments is long and impressive. Although challenges remain, I am confident you will continue to work together with state, local and federal agencies towards the successful resolution of community objectives.

I regret not being at today's meeting and delivering this message to you in person. I am attending a state-wide conference in Missoula.

Sincerely and with best wishes to you all,

Dan

Appendix 3

October 9, 2003

W.R. Grace & Company
7500 Grace Drive
Columbia, Maryland 21044

To Whom It may Concern:

We have recently learned that some individuals who signed up for coverage under the Grace Medical Plan are not receiving 100 percent coverage of medical costs as was promised by W.R. Grace & Company when the plan was unveiled in 2000. We have learned that some qualified individuals on the plan are being billed for portions of medical services and drugs that are not being paid, as promised, by Grace.

We respectfully request that W.R. Grace & Company honor its commitment to pay 100 percent of the medical costs incurred by persons signed up for the Grace Medical Plan. We respectfully request that W.R. Grace & Company take whatever steps are necessary to ensure that persons signed up for the Grace Medical Plan are never billed by any entity for any services or drugs they receive under the plan. The mechanism by which 100 percent coverage is provided should be a matter of negotiation between Grace and the doctors, hospitals and pharmacies providing service.

The qualified individuals who signed up for 100 percent coverage under the Grace Medical Plan are already burdened with physical and emotional suffering. They should not be further burdened with any of the expenses connected with any treatment or drugs for any asbestos-related diseases.

Yours very sincerely:

Please see attached signature page.

Libby Area Community Advisory Group

Kerry Beasley
St. John's Lutheran Hospital

Gayla Benefield
LCAVRO

George Bauer
City of Libby

Dr. Brad Black
Lincoln County Health Officer
CARD

Eileen Carney
State Rep., Dist. 82

Bob Dedrick
Asbestos Victim

Richard Fleshe r
Libby Resident

Robert H. Foote
Libby Ministerial Association

Ken Hays
Lincoln County Council on Aging

Li George Keck
Lincoln County Community Health Center

David Latham
The Montanian Newspaper

K.W. Maki
Libby School District #4

Clinton Maynard
Area Asbestos Research Group

Franklin Mills
Citzen

Rick Palagi
St. John's Lutheran Hospital

Norita Skramstad
Asbestos Victim

Gary Spencer
Glacier Bank

Gary D. Swenson
Libby Volunteer Fire Dept.

Mike Switzer
Asbestos Victim

Leroy Thom
Former W.R. Grace employee

Sandy Wagner
LCCHC

Don Wilkins
Lumber & Sawmill Workers #2581


Photos courtesy of Dudley Dana, Dana Gallery