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Doctor Shortage in Wyoming; “Almost Impossible to Recruit”

in News/Health care
Doctor Shortage in Wyoming; “Almost Impossible to Recruit”
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Wyo Hospital Assoc. President: Federal changes makes it almost impossible for us to be competitive and for us to recruit especially family practice physicians in these rural areas where they’re needed the most.

By James Chilton, Cowboy State Daily

CHEYENNE – When it comes to sheer numbers, Wyoming’s doctor shortage isn’t all that bad, on paper at least.  Just two dozen additional full-time outpatient physicians would be enough to meet the primary care needs of the nearly 188,000 Wyomingites living in federally-designated Health Professional Shortage Areas, or HPSAs.

“The population of designated HPSAs in Wyoming for primary care is 187,903, and only 53.81 percent of that population’s need is met,” said Keri Wagner, of the Wyoming Health Department’s Office of Rural Health. “The practitioners needed to remove that designation is 24 for the entire state.”

While it might not sound like much, getting those 24 full-time doctors into the state, getting them to the communities where they’re needed most, and offering them the compensation and quality of life needed to keep them here have proven uniquely difficult in the Cowboy State. Federal and state programs have made some headway in the effort to bring more doctors, dentists and psychiatrists to all corners of Wyoming. But while the state’s reputation for wide-open natural splendor brings in the tourists and outdoorsmen, it’s not necessarily what most doctors are seeking when looking to relocate.

“It really takes a specific type of person, someone who grew up in these frontier communities that really wants to get back to practicing someplace where they’re relatively isolated. If they’re outdoorsmen or like cross-country skiing or hunting, sure; but there are long distances to get to any other type of entertainment,” Wagner said. “We’re surrounded by states with larger population centers, more enrichment opportunities and educational opportunities, so it can be a really tough sell for some communities that don’t even have a supermarket.”

The HPSA designation seeks to help with this by grading facilities, geographic regions and specific populations on criteria like patient-to-provider ratio, percentage of the population living below the federal poverty level and travel time to the nearest source of care. From this, hospitals, clinics and geographic areas are scored, with higher scores getting the most attention from the U.S. Health Resources and Services Administration.

“If they have the HPSA designation for any of the three disciplines (primary care, dental or mental health services) it opens up the opportunity to participate in the National Health Service Corps,” Wagner said. “We have roughly 30 corps participants every year.”

The National Health Service Corps tries to get practitioners to where the need is by offering scholarships and loan repayment programs to fledgling doctors in exchange for an agreement to work in a designated HPSA for at least two years. Physicians working in geographic HPSAs can also obtain additional bonus quarterly payments from the Centers for Medicare and Medicaid Services.

For HPSA designation and related support, practitioners must submit reports updating the state on statistics such as doctor-to-patient ratios.

“It’s important enough they’ll return their surveys if they’re afraid they’ll lose their designation,” Wagner said. “I’ve seen people where they receive the bonus payment, but there was some cutoff or something wrong with the timing, where the HPSA designation goes away and they have to return it. I think one of the big things that’s happened is the population is so small that just the loss of a quarter of an FTE (full-time equivalent, i.e. 40 hours of work per week) can make or break a designation.”

That’s been a continuing cause for concern for Eric Boley, president of the Wyoming Hospital Association. Boley agreed with Wagner’s assessment that, for whatever reason, the HPSA system seems weighted to apply to more densely-populated areas, where small changes in population don’t move the needle as much.

“The feds have changed the way the HPSA scoring is calculated based on service areas, so areas I and my members would designate as shortage areas no longer meet their criteria,” Boley said. “For example, south Lincoln County used to easily qualify for HPSA funding, where northern Lincoln County, the Star Valley area, didn’t have some of the challenges. But now because of criteria changes, the whole area is lumped into one.”

As a result, Boley said some of the state’s most vulnerable rural communities are left with few resources to attract medical talent from larger hospital systems, and even those that do have the resources have to make steep offers to even stand a chance.

“My facilities are having to pay, in some cases, the 95th percentile for salaries, with sign-on bonuses and really lucrative living expense packages,” Boley said. “It makes it almost impossible for us to be competitive and for us to recruit especially family practice physicians in these rural areas where they’re needed the most.”

Wagner noted the state has led its own effort to try to provide a little more financial leverage to small communities through the Wyoming Provider Recruitment Grant Program, which provides up to $50,000 to a hospital, clinic or community organization attempting to recruit a healthcare provider. Initially funded for the 2009-10 biennium, the program doesn’t level the playing field, Wagner said, but it has helped to recruit more than a dozen physicians, psychiatrists and, following a 2015 legislative change, other health professionals like registered nurses or occupational therapists.

Like most programs, Wyoming’s provider recruitment program has some strings attached that have kept it from being fully utilized. One big problem is that the grants are meant for reimbursement, meaning whoever’s doing the hiring needs to have the money up front and has to have someone recruited within one year for the payments to come through. 

“If they don’t recruit within that one year, they don’t get any money. If they do recruit, the provider has to start within six months of the date they sign them,” Wagner said. “So, is this entity able to fund all of this up front and wait for the reimbursement? Our neediest have applied, but they couldn’t go anywhere without money to front it.”

As such, Wagner said applications made through the program dropped from 45 in the 2009-10 biennium to just nine in the following biennium, and they have remained low ever since. But for those hospitals able to navigate the process and pay for the initial recruitment process, the program has proven a useful tool.

“I think it’s successful in that it provides funding to help recruitment at safety-net facilities. These are organizations that don’t have a ton of funding; they have a hard time competing with larger hospital systems in surrounding states,” she said. “So when a provider is contacted and they’re mulling over whether they should go to a rural health clinic in Colorado that’s offering an $80,000 loan repayment on top of a $40,000 sign-on bonus, versus this hospital in Wyoming … this program improves Wyoming’s negotiating position. It provides them with a little bit more clout.”

Missile systems upgrade could bring billions to SE Wyoming

in Economic development/News/military/Business
1467

If the missiles under control of F.E. Warren Air Force Base are made part of a massive upgrade program, Cheyenne could see challenges in managing the resulting growth, according to the former head of the Wyoming Business Council.

Bob Jensen, now part of Wyoming Entrepreneurs, said F.E. Warren’s involvement in the Ground Based Strategic Missile Upgrade program could generate growth among existing businesses and bring in new businesses as well.

“So this is going to be a big change and managing that change is as big a deal as having the opportunity in the first place,” he said.

Boeing and Northrop Grumman are in competition for a project to upgrade the nation’s Minuteman III intercontinental ballistic missiles, about 400 of which are deployed in Montana, North Dakota and Wyoming, at an estimated cost of $90 billion.

Jensen said if the missiles in Wyoming are made part of the project, opportunities for growth would be seen throughout Cheyenne.

“People that are already here will have an opportunity to grow their businesses in relation to this if they want to,” he said. “But there will be new businesses that will come in and new workforce that comes in.”

To take full advantage of the program, Wyoming and Cheyenne will need to be able to look ahead and act on the opportunities it provides, said Eric Trowbridge, the founder of Cheyenne’s Array School of Technology and Design.

“We must have ‘leapfrog’ moments,” he said. “Wyoming does something that no one else has done before. We have to have that courage to be able to say we’re going to do it and leapfrog ahead of all the other states to do it.”

Boeing and Northrop Grumman have been awarded three-year contracts for the preliminary design phase of the upgrade.

An upgrade to Wyoming’s nuclear weapons system could be coming to Cheyenne’s FE Warren Air Force Base — but is Cheyenne ready?

Invention of Taco Johns potato ole

in Food and Beverage/Business
1463

By Cowboy State Daily

If you’ve ever eaten at a Taco Johns you know about the potato ole.

That crispy, crunchy, salty, seasoned tater tot so good you would never call it just a tater tot. But how did the potato ole become a central player on the menu of a Mexican fast-food joint?

We’ve got the skinny on the history of the deep fried delicacy that almost burned out before it blew up as a west-Mex sensation.

The Decline of the Whiskey Mountain Bighorns

in Cat Urbigkit/Column/Range Writing/wildlife
Big Horn Sheep
1458

By Cat Urbigkit, Range Writing columnist for Cowboy State Daily

The Whiskey Mountain bighorn sheep herd has made Dubois, Wyoming an international stop for people interested in this species of mountain royalty, with many residents keep spotting scopes trained on the hillsides above town for constant sheep viewing. This rustic western community also hosts the National Bighorn Sheep Center.

Whiskey Mountain once held the largest concentration of wintering bighorn sheep in the country, but the herd began to decline in the 1970s. In 1975, researchers found the sheep herd was consuming more than 90 percent of the annual vegetative growth on its wintering grounds, and herd members were afflicted with poor health, indications that there was inadequate forage and the herd had overpopulated its range.

Those researchers (led by the late and sorely missed wildlife veterinarian Dr. Tom Thorne of the Wyoming Game & Fish Department) predicted that any added environmental stress could result in a catastrophic disease outbreak, which came true in the early 1990s. The population has continued to struggle since that time, with the herd currently numbering about 400 animals.

Although the herd is now only utilizing less than half the annual forage growth on its winter range, there continue to be indications that the herd is subject to some unknown nutritional stress on its summer range.

According to the draft management plan for this herd, “Underpinning the nutritional issued identified in this herd is now the persistence of bacteria and other pathogens believed to have serious health repercussions for the population.”

The herd has multiple species of bacteria related to pneumonia in bighorn sheep, as well as sinus tumors, and other diseases and parasites.

“At this point managers do not know if poor sheep health in the Whiskey Mountain Bighorn Sheep herd is strictly due to pathogens and parasites or if the persistence of pathogens and parasites is the result of nutritional stress,” according to the draft plan.

Domestic sheep and goats have traditionally been blamed for bighorn sheep die-offs, regardless of whether there was any documented contact between wild and domestic sheep.

In this case, “when and how bacterial pathogens were introduced to the bighorn sheep population is unknown, but it is likely environmental stress associated with severe winter conditions resulted in the disease outbreak and die-off event.”

The last known record of domestic sheep use in the Whiskey Mountain area was in the early 1960s, and all domestic sheep and goat grazing has been banned on the area of the Shoshone National Forest used by this herd – even the use of pack goats. Despite there being no domestic sheep in the herd area for decades, the draft plan calls for the Wyoming Game & Fish Department (WG&F) to work with the National Bighorn Sheep Center to “develop a strategy to provide educational materials to domestic sheep or goat owners” and to coordinate with federal agencies on the need to maintain separation between wild sheep and domestic sheep and goats.

In my view, that’s pretty much a waste of time and money: As if there is a domestic sheep producer in the West that hasn’t heard this refrain before. It would be far more suitable to invite wool growers to the table rather than having bighorn sheep advocates trying to tell domestic sheep producers how to manage their flocks. Sheep producers know that there are a variety of ways of keeping bighorns and domestic flocks separated, but some bighorn advocates view ridding the range of domestic sheep as the only way to ensure separation, setting the two up for conflict rather than working together.

In addition, new research on a pathogen known to cause pneumonia in bighorn sheep has been recently been documented to occur in moose, mule deer, white-tailed deer, antelope, and caribou. But WG&F maintains that these other species are not a component of the bighorn problem.

The presence of a new wolf pack on Whiskey Mountain has added a new pressure to the mix for the bighorn herd. The increased wolf activity has changed the behavior and distribution of the bighorn herd on its winter range, with the herd shifting up the mountain, into higher-elevation, less accessible, and more rugged terrain as the wolves have moved onto the lower-range winter habitat for the sheep, and the area elk population has also moved down onto traditional sheep winter range. The draft plan notes that while direct predation on sheep hasn’t been observed to be an issue, “the displacement being caused by wolves adds another potential stressor to an already nutritionally and conditionally stressed population.”

WG&F has started a three-year research project aimed at understanding lamb mortality and assessing summer habitat conditions, with the WG&F Commission kicking in $350,000 for the first year. Since much of the herd’s summer range is within the Fitzpatrick Wilderness, the U.S. Forest Service has agreed to approve the study components, including backcountry camps, experimental habitat treatments, and the use of a helicopter to capture bighorns in the wilderness area.

WG&F will hold two workshops this week to discuss the draft plan, which can be found at this link. The first workshop will be held June 5, at 6 p.m. at the Dubois Headwaters Arts and Conference Center, and the second will be June 6, at 6 p.m. in the WG&F’s Pinedale office.

Cat Urbigkit is an author and rancher who lives on the range in Sublette County, Wyoming. Her column, Range Writing, appears weekly in Cowboy State Daily.

There’s a whole lotta Mexican goin’ on: Taco 🌮 Johns celebrates 50

in News/Business
1455

“If you’ve got a tiger by the tail, hang on. I knew this was a tiger and I was ready to go right then,” that’s how Taco Johns co-founder Harold Holmes remembers deciding to embark on an entrepreneurial adventure that started in Cheyenne, Wyoming and grew to hundreds of restaurants over 50 years.

Taco Johns celebrates 50 years in business this week and we’ve got the skinny on how a humble taco stand on Carey Ave. – that was built in a week – turned into a national fast-food chain serving tacos (and potato oles) to fans in 23 states.

Modern Marvel: 90-year-old plane takes to the Wyoming skies

in News/Transportation
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The eyes go the skies when vintage aircraft signal their arrival.

A group of experimental aviators made it to Casper this weekend to spread the joy of flight and show off a 90-year-oold passenger plane from the era of Charles Lindbergh.

Frank Gambino tells us the story of the Ford Tri-Motor airplane, nicknamed the Tin Goose.

Triumph High School grads overcome adversity on the road to a diploma

in News/Education
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At Triumph High School, students overcome challenges outside the classroom in addition to the academic rigors of earning a high school diploma.

Their stories are remarkable and, not long ago, the likelihood of finding them in caps and gowns today was far from certain.

“There are a lot of complicated variables. I call it a constellation of variables that intersect and make schooling sometimes very difficult for our young people,” said Triumph High Principal Mike Helenbolt.

In a pre-graduation ceremony, 2019 graduate Chasely Moon thanked her son, in addition to teachers and advisors, for giving her the motivation to stay in school and earn her degree.

“I probably wouldn’t have put forth the effort to finish if I hadn’t realized how hard it was to make a living without a high school diploma,” Moon said.

Wyoming helium production helps keep world supply afloat

in News
Helium shortage
1446

By James Chilton, Cowboy State Daily

CHEYENNE – Helium may be the second-lightest element, but it’s weighing heavily on a lot of minds these days as the world struggles with its third global shortage in just 14 years.

It’s gotten bad enough that, when party supply superstore Party City announced earlier this month it plans to shutter 45 of its 870 stores in the U.S., many outlets pointed to helium as the culprit. Party City has since said the closures are unrelated to the helium shortage, but it has acknowledged that some stores have had trouble fulfilling balloon orders due to inconsistent helium supplies, and it hopes to have a new commercial supplier in place by the summer.

It may not be the first thing that springs to mind when thinking of Wyoming, but the Cowboy State plays a key role in keeping the helium supply chain afloat, providing up to 30 percent of the world’s supply.

While most people probably know helium best for its role in the party balloon business, or for the funny way it raises the pitch of your voice, it’s actually one of the most critically important elements on the planet. In fact, helium is one of 35 mineral materials considered essential to U.S. national economic and security interests, as recently defined by the Department of the Interior.

That’s because, aside from making balloons and blimps float, helium has many important uses in the technology sector.

With the lowest boiling point of any element at -452 degrees Fahrenheit, liquid helium is used as a coolant for magnets in MRI machines and for research operations like Europe’s Large Hadron Collider particle accelerator. Because it’s light and nonreactive, it’s also used as a shielding gas in arc welding, and it’s added to air tanks to make it easier for lungs to take in oxygen during deep ocean dives.

“It’s almost too valuable to fill party balloons with,” said Scott Quillinan, the director of research at UW’s School of Energy Resources.

But while it makes up about a quarter of all the matter in the universe, helium is surprisingly hard to come by on Earth. The name is a bit of a giveaway – helium was named for the Greek sun god Helios, since it was first detected not on Earth, but as part of the sun’s spectral light signature, caught during a solar eclipse in 1868.

On Earth, it makes up just 0.0005 percent of the air we breathe, and while other important gases like hydrogen and oxygen can be easily separated from more complex molecules, helium is notoriously stable and doesn’t combine with other elements.

That leaves just one primary source for helium on Earth: deep within the ground. As radioactive elements like uranium and thorium break down, they throw off helium atoms that then become trapped in natural gas formations.

“There are competing hypotheses as to why there is even helium in natural gas anywhere,” said geologist Ranie Lynds, the manager of the Wyoming State Geological Survey’s Energy & Mineral Resources division. “Some people have it as being mantle-driven, coming from a lot deeper in the earth, and because it’s so light it’s able to make its way up to the surface where it’s stored with natural gas.”

“Other people have argued it forms more from uranium and thorium decay in sedimentary rocks, then it’s moved along with water through these systems,” Lynds added.

Regardless of how it got there, there’s still not much to go around – helium comprises less than 0.3 percent of most commercial natural gas deposits. But in a handful of places those concentrations rise to as high as 8 percent, making helium extraction economically viable.

In Wyoming, all the state’s commercially-produced helium comes from the LaBarge field in western Sublette County. Natural gas extracted from LaBarge is piped down to ExxonMobil’s Shute Creek natural gas processing plant in eastern Lincoln County, where the helium is separated out from other gases like methane and carbon dioxide.

“The CO2 is sold for enhanced oil recovery opportunities and the methane is used for natural gas sales,” Quillinan said. “The helium concentration is only about 0.6 percent of the gas that comes out, but there’s not many places in the world where you can find helium, so even at those low percentages, it becomes economic to produce.”

 Quillinan noted that helium has to be cooled to almost absolute zero – the lowest physically-possible temperature – in order to be liquefied for storage and shipment. And even then, helium’s ultra-light nature makes it hard to keep contained. Once it’s gone, it’s gone for good, since even Earth’s gravity isn’t enough to keep it from just floating off into space.

“It can be very difficult to handle,” Quillinan said. “I’m an isotope geochemist, and one problem with even sampling isotopes of helium is you can’t use glass containers, because it’ll just slip through the glass.”

 The hassle is more than worth it, however. At least ExxonMobil seems to think so: figures published in 2014 in the scientific journal “Minerals” show that Wyoming accounted for 43 percent of U.S. helium production and 31 percent of global production from 2000 to 2012.

 “Looking at the numbers for 2012 specifically, Wyoming does top the list, then very close behind it is Kansas, followed by Texas, then Colorado and Oklahoma,” Lynds said. “Right now there’s pretty significant production in Wyoming and I would expect that to continue.”

In January, Wyoming State Geologist Erin Campbell wrote that, along with uranium, helium has some of the best development potential of any mineral material in the state. In addition to the known supplies at LaBarge and elsewhere in southwest Wyoming, Campbell said the WSGS “estimates 14.78 billion cubic feet of marginally economic and subeconomic helium resources exist … in the Greater Green River, Wind River, Powder River, and Bighorn basins and the western Wyoming thrust belt.”

But while those untapped resources may one day help to meet global demand for the gas, industry experts expect the current shortage will likely last through the remainder of this year, unless either demand starts dropping or until other large-scale helium projects in Qatar and Russia come online in 2020 and beyond.

VA to implement Mission Act, cutting wait times, enhancing healthcare programs

in Health care/military
File photo
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By Ike Fredregill, Cowboy State Daily

A congressional act going into effect June 6 could make it easier for Wyoming veterans to access the health care providers of their choice. The Mission Act will replace the Choice Act of 2014, which was adopted as the congressional response to extreme wait times experienced by veterans seeking medical care through the Department of Veterans Affairs.

“The Choice Act was a three-year law, which was intended solely for the purposes of pulling the VA into a newer era of community care,” said Sam House, a Cheyenne VA Medical Center spokesperson. “Then, President (Donald) Trump extended it for a year. The Mission Act, however, does not have a sunset, so it will be in place until Congress decides to remove it.”

With the Choice Act, veterans could seek primary and mental health care services from a local health care provider rather than from a VA facility if they lived outside a 40-mile radius of a VA medical center or could not schedule an appointment with their primary care provider at the VA within 30 days.

The Mission Act reduces those standards to a wait time of 20 or more days or a drive time of more than 30 minutes.

“They are not using specific matrix to look at drive times, but rather looking at the average drive time and taking into account heavy traffic periods,” House explained. “A guy living in Denver could live 5 miles from the VA, but it might take him 45 minutes to get there.”

For specialized care, the new act reduces the veterans’ wait time to be eligible for services at non-VA facilities from 30 days to 28 and changes the 60-mile radius requirement to a 60-minute radius.

“Congress is focusing on ensuring our vets are getting the best possible care as quickly as they need it,” House said.

Enhancing programs

In addition to easing access requirements, the Mission Act seeks to improve services already in place such as tele-health options, caregiver programs and VA infrastructure.

“The Mission Act streamlines and improves community care,” House said. “It establishes a new urgent care benefit for our veterans, and it expands caregiver eligibility.”

When the Choice Act was implemented, veterans were given the opportunity to seek healthcare providers outside VA facilities, which is referred to as community care, he said.

The VA’s internal software, however, did not communicate with the myriad programs used by health care providers outside its facilities. Simple tasks such as transferring medical records and authorizing payments required mountains of paperwork as well as numerous case-worker hours, House explained. The Mission Act seeks to streamline the process through installing new software, HealthShare Referral Manager (HSRM).

“HSRM is an end-to-end healthcare referral system,” said Josh Benavente, Cheyenne VA Community Care supervisor. “That’s where the VA will build our authorizations for payments and providers can submit medical records.”

The new system goes live in June.

“The biggest problem it’s fixing is previously we were relying on too many outdated programs to get information to and from community providers,” Benavente said. “It allows the VA to communicate with community providers faster and easier.”

Eligibility for the VA’s caregiver program is also slated to expand to include veterans from all eras of service. The expansion is scheduled to roll out during the next two years, starting with veterans who were injured on or before May 7, 1975.

On the tele-health front, the act could facilitate community partnerships in rural areas to increase long-range, video and phone healthcare-conferencing accessibility, House said.  

“What the Mission Act will do is strengthen our ability and reason for going into communities to establish a centralized tele-health port,” he explained. “We have a number of veterans that don’t have internet capability, but they want to stay with the VA and can’t make the trip to the Cheyenne VA every time.”

One such program could soon provide veterans living near Saratoga an opportunity to use equipment at the Saratoga Care Center to access Cheyenne VA tele-health programs, House added.

Bureaucracy

As June 6 rounds the corner, House said the VA is racing to ensure the transition is smooth. 

“It’s been a mad rush for all of the VA to be trained by June 6,” he said. “There are so many pieces and parts to the act.”

Despite more programs and enhanced services, House said the act will not likely lead to an increase of staffing at the Cheyenne VA.

Cowboy State Daily talked to several veterans who were unaware of the changes coming to the VA, but most said they would like the Mission Act to make it easier for veterans living in rural Wyoming to enter the community care program.

“The Choice Program didn’t work too well because of all the bureaucracy,” said John Hursh, a Laramie resident and former captain in the U.S. Marine Corps Reserve. “So, I’m hoping the Mission Act can fix some of that.”

“And they were proud to do so”: A moving Memorial Day tribute to the fallen

in News/military
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Start your day with gratitude and patriotism.

Watch this moving report from Monday’s Memorial Day service in Cheyenne. The ceremony offered a moving tribute to those who gave all in service to our country and a great reminder to share with our children and grandchildren of the blessing of being born in the land of the free and the home of the brave.

“These people gave their lives,” said Air Force veteran Floyd Watson. “Eighteen, nineteen, twenty-year-old kids gave their lives in sacrifice to this country. And they were proud to do so.”

The event was held at Cheyenne’s Beth El Cemetery and attended by area active duty military, veterans, local families and elected officials including Cheyenne Mayor Marian Orr.

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