[Federal Register Volume 81, Number 162 (Monday, August 22, 2016)]
[Notices]
[Pages 56660-56662]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2016-19938]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration


Proposed Changes to the Black Lung Clinics Program

AGENCY: Health Resources and Services Administration (HRSA), HHS.

ACTION: Request for Public Comment on Proposed Changes to the Black 
Lung Clinics Program for Consideration for the FY 2017 Funding 
Opportunity Announcement Development.

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SUMMARY: This notice seeks comments on a range of issues pertaining to 
the Black Lung Clinics Program (BLCP), which will be competitive in 
Fiscal Year (FY) 2017. HRSA's Federal Office of Rural Health Policy 
allocates funds for state, public, or private entities that provide 
medical, educational, and outreach services to active, inactive, and 
retired coal miners with disabilities. Funding allocations take into 
account the number of miners to be served; their medical, outreach, and 
educational needs; and the quality and breadth of services that are 
provided. HRSA requests feedback on how to best determine the needs of 
coal miners and their families, given the available data, and how to 
better equip future BLCP grantees to meet those needs.

DATES: Submit written comments no later than September 21, 2016.

ADDRESSES: Written comments should be submitted to [email protected].

FOR FURTHER INFORMATION CONTACT: Allison Hutchings, Program 
Coordinator, Black Lung Clinics Program, Federal Office of Rural Health 
Policy, Health Resources and Services Administration, 
[email protected].

SUPPLEMENTARY INFORMATION:

I. Background

a. Authorizing Legislation and Program Regulations

    BLCP is authorized by Section 427(a) of the Federal Mine Safety and 
Health Act of 1977 (30 U.S.C. 937(a)), as amended, and accompanying 
regulations found at 42 CFR part 55a (``BLCP regulations''). HRSA began 
administering the program in FY 1979, when $7.5 million was 
appropriated. HRSA awarded approximately $6.5 million to clinics in FY 
2015.
    The primary goal of the BLCP is to reduce the morbidity and 
mortality associated with occupationally-related coal mine dust lung 
disease. The BLCP regulations (42 CFR part 55a) state that BLCP 
grantees must provide for the following services to active and inactive 
miners, in consultation with a physician with special training or 
experience in the diagnosis and treatment of respiratory diseases: 
primary care; patient and family education and counseling; outreach; 
patient care coordination; antismoking advice; and other symptomatic 
treatments. Additionally, BLCP grantees must serve as payers of last 
resort and be able to administer, or provide referrals for, U.S. 
Department of Labor (DOL) disability examinations.

b. Eligibility and Funding Criteria

    The BLCP funding opportunity is open to any state or public or 
private entity that meets the requirements of the BLCP as described 
above. These entities include faith-based and community-based 
organizations, as well as federally recognized Tribes and Tribal 
organizations.
    The BLCP regulations state that the funding criteria for applicants 
should take into account: (1) The number of miners to be served and 
their needs; and (2) the quality and breadth of services to be 
provided. The regulations also state that ``the Secretary will give 
preference to a State, which meets the requirement of this part and 
applies for a grant under this part, over other applications in that 
State''.

c. Application Cycle

    HRSA administers the BLCP over 3-year grant cycles. The program was 
last competitive in FY 2014, and current BLCP grantees finished their 
second year of the cycle on June 30, 2016. The program will be 
competitive again in FY 2017.

II. Current Challenges

a. Growing Need for Black Lung Services

    In FY 2000, surveillance data from the Centers for Disease Control 
and Prevention's National Institute of Occupational Safety and Health 
(NIOSH) showed an unexpected increase in the national prevalence of 
coal workers' pneumoconiosis (CWP), also known as black lung disease, 
after nearly three decades of steady decline following the enactment of 
the Federal Coal Mine Health and Safety Act of 1969. The overall CWP 
prevalence among U.S. coal workers declined from 11 percent in 1970 to 
2 percent in 1999. However, since 2000, the prevalence of CWP has 
increased to 3 percent and continues to rise. According to NIOSH 
surveillance data, the rise in CWP has been the most severe among coal 
miners

[[Page 56661]]

in Kentucky, Virginia, and West Virginia. Compared with coal miners in 
other states, these miners tend to be younger, with fewer years of work 
experience in underground mines. Investigators from NIOSH reported that 
the prevalence of progressive massive fibrosis (PMF), the most severe 
form of black lung disease, increased 900 percent between 2000 and 
2012, affecting over 3 percent of miners with over 25 years of work. 
This level of prevalence of PMF has not been seen since the 1970s. 
Additionally, NIOSH has reported that coal miners are developing severe 
CWP at relatively young ages.
    Finally, the U.S. coal industry is currently experiencing a 
downturn. Industry analysts estimate that nearly 50 coal companies have 
sought bankruptcy court protection since 2012, resulting in layoffs 
and, in some cases, lost retirement benefits for coal miners. According 
to a 2016 report by the Appalachian Regional Commission, Appalachian 
Kentucky experienced a coal mining job decline of 56 percent between 
2011 and 2015, while Tennessee and Virginia both experienced declines 
of approximately 40 percent during the same time period. The West 
Virginia Office of Miners Health Safety and Training has estimated that 
there are currently 12,000 coal miners employed in the state, down from 
22,000 in 2011. Widespread coal mining job losses have also been 
reported in other states such as Pennsylvania, Ohio, and Alabama. These 
trends have the potential to affect coal miners' economic welfare and, 
by extension, their ability to access or afford health care. Indeed, 
some current BLCP grantees have noted in their annual progress reports 
to HRSA, submitted April 2016, and in written email communication ahead 
of the March 2016 HRSA BLCP Grantee Workshop, that they have witnessed 
a recent uptick in the number of coal miners visiting their clinics, 
which some attribute to industry layoffs.

b. Ongoing Challenges in Meeting Those Needs

    Current BLCP grantees reported facing several challenges in meeting 
the needs of coal miners in their service areas during a March 2016 
BLCP Grantee Workshop hosted by HRSA. First, recruitment, training, and 
retention of qualified clinical and benefits counseling staff remain 
difficult, particularly in rural areas. Second, coal miners often face 
transportation and other barriers to accessing health services, which 
is problematic given that many suffer from chronic conditions that 
require regular management and treatment. Third, BLCP grantees have 
indicated that some miners, including those who have been laid off or 
are not part of a union, are difficult to locate, which can complicate 
outreach and service delivery efforts. Finally, there continues to be a 
shortage of clinicians willing and able to perform exams related to the 
emerging DOL standards for x-rays, pulmonary testing, and medical 
documentation, particularly in rural areas.

c. Limited Available Data

    Overarching these challenges is the lack of a single, 
comprehensive, national dataset that contains information on active, 
inactive and retired, and disabled U.S. coal miners who have worked in 
surface and underground mines. DOL's Office of Workers' Compensation 
Programs and Mine Safety and Health Administration, along with NIOSH's 
Coal Workers' Health Surveillance Program, each regularly collect 
health and safety data on coal miners, but these data address specific 
and separate aspects of this population. HRSA also collects yearly 
performance data from BLCP grantees, but these data are in aggregate 
form making it problematic to analyze patient-level data or link to DOL 
or NIOSH's datasets. As a result, it is difficult to ascertain both the 
total number of active, inactive and retired, and coal miners with 
disabilities in a given service area, as well as the complete health 
and wellness profile of U.S. coal miners. This makes it difficult for 
HRSA to assess where U.S. coal miners reside and what their needs are. 
Per statute, HRSA is required to allocate BLCP grant funds based in 
part on ``the number of miners to be served and their needs.'' 
Additionally, the lack of comprehensive data on coal miners is a 
challenge to current BLCP grantees that use BLCP funds to target and 
deliver services to miners.

III. FY 2014 Funding Approach and Current BLCP Cohort

a. Overview of FY 2014 Funding Approach

    In FY 2014, HRSA tested a new funding approach that aimed to 
respond to the growing national need for BLCP services, as well as the 
BLCP regulations' requirement to allocate BLCP grant funds according 
to: (1) The number of miners to be served and their needs; and (2) the 
quality and breadth of services to be provided. The new funding 
approach enabled individual applicants to apply for a specific tier of 
funding, depending on the level of services they intended to provide 
(see pp. 6-9 of the FY 2014 Funding Opportunity Announcement). 
Historically, the mix of BLCP grantees and applicants has been broad in 
terms of those who are very clinically focused and those who are more 
geared towards outreach, education, and counseling. The tiered-based 
funding approach was designed, in part, to account for these 
differences. Additionally, the funding methodology took into account 
available data on the number of coal miners and coal mines in a service 
area, as reported by the U.S. Department of Energy's Energy Information 
Administration (EIA) and other national, state, and local resources.

b. Current BLCP Cohort

    Following a competitive application process, HRSA allocated 
approximately $6.5 million among 15 BLCP grantees. These grantees 
provided medical, outreach, educational, and counseling services to 
11,843 miners across 14 states in FY 2014.

c. Black Lung Center of Excellence

    HRSA also funded one Black Lung Center of Excellence (BLCE) through 
a cooperative agreement in FY 2014 to strengthen the quality of the 
BLCP and respond to some of the challenges faced by BLCP grantees and 
the program as a whole, including around the emerging clinical 
requirements related to DOL's black lung claims process.

IV. Request for Public Comment on Next Funding Opportunity Announcement 
(FOA)

a. Background

    The BLCP will be competitive again in FY 2017, and HRSA is seeking 
public comment on issues pertaining to the program, including:

b. Funding Approach

    Following the release of the new funding approach in FY 2014, some 
stakeholders expressed concern that the funding tiers increased the 
administrative burden on applicants and, in some cases, reduced funding 
for applicants that experienced a high demand for black lung services 
in their service areas. With this request, HRSA invites public comment 
on the FY 2014 funding approach and suggestions for other funding 
methodologies that will allocate BLCP grant funds based on the 
healthcare needs of coal miners and the ability of applicants to meet 
those needs, while minimizing service disruption, aligning with the 
program's statutory and regulatory requirements, and taking into 
account the amount of available funding.

[[Page 56662]]

    One approach HRSA would like to seek feedback on includes a service 
area competition whereby HRSA allocates funds to states based on the 
need for services (which includes the number of miners in the state) 
and the implications of taking into account historical funding amounts 
in administering the program.

c. Determining Need

    HRSA's FY 2014 funding methodology aimed to better align the BLCP 
with the regulations, which require HRSA to allocate funds based on: 
(1) The number of miners to be served and their needs; and (2) the 
quality and breadth of services to be provided. To that end, the FY 
2014 funding methodology took into account the number of coal miners 
and coal mines in a service area, as reported by EIA and other 
national, state, and local resources, as well as the level of services 
an applicant intended to provide. HRSA recognizes that these data do 
not necessarily encapsulate important factors like disease severity and 
comorbidity, disability, and employment status, all of which could 
affect the time and resources grantees must devote to delivering health 
and social services to coal miners. With the recent downturn of the 
U.S. coal industry, and the corresponding layoffs of coal miners, the 
numbers of active coal miners and coal mines in a service area may not 
be the most accurate indicators of need for services. Therefore, HRSA 
invites public comment on how to better define and measure the diverse 
needs of coal miners based on publicly available data to ensure that 
HRSA allocates BLCP grant funds to areas of the country where they are 
most needed.

d. Data Collection

    Currently, BLCP grantees report performance data on the number of 
coal miners they serve and the number and type of services they provide 
to HRSA. These aggregated data provide little insight into the quality 
of services clinics provide, nor relevant factors such as comorbid 
conditions, smoking history, and insurance coverage. Requiring BLCP 
grantees to collect and report on patient-level data would strengthen 
the quality of the BLCP by enabling HRSA to better understand coal 
miners' needs, the ability of BLCP grantees to meet those needs, and, 
importantly, how to better allocate BLCP grant funds. Additionally, 
given that the majority of coal miners served by BLCP grantees are 
retired, collecting patient-level data would enable HRSA to add to the 
limited body of knowledge on this population.
    However, despite the benefits of patient-level data collection, 
HRSA recognizes that this process may be administratively and 
financially burdensome for BLCP grantees. Therefore, HRSA invites 
public comment on whether it should require grantees to collect and 
report patient-level data, either through the current performance 
measurement system or a separate black lung clinical database.

e. The Black Lung Center of Excellence (BLCE)

    In FY 2014, HRSA funded one BLCE through a cooperative agreement to 
focus on the quality aspect of the BLCP. The current BLCE grantee, with 
assistance from HRSA, has implemented a number of activities aimed at 
achieving HRSA's goals around quality, including:
     Developing and launching the BLCE Web site to provide BLCP 
grantees, miners, and others who provide services to miners with 
educational expertise and resources on coal mine dust lung disease;
     Creating four training modules in collaboration with the 
DOL, Division of Coal Mine Workers Compensation, for medical providers 
and Black Lung examiners that provide in-depth information on 
screening, diagnosis, and treatment of coal mine lung dust disease;
     Providing technical assistance to BLCP grantees; and
     Developing and piloting the Black Lung Clinical Research 
Database (REDCap) to standardize clinical data collection and 
performance data submission by HRSA BLCP grantees.

HRSA invites public comment on how HRSA can better leverage the BLCE's 
expertise and quantify the BLCE's impact on BLCP grantees and the coal 
miners they serve through performance measures.

f. Timeliness and Quality of DOL Exams

    One of the goals of the BLCP, as outlined in the FY 2014 funding 
opportunity announcement, is to ``provide well-reasoned medical 
opinions and timely scheduling/completion of DOL medical exams to 
facilitate the filing of Federal Black Lung Benefits claims.'' HRSA 
proposes to work with DOL's Office of Workers' Compensation Programs 
(OWCP) to hold BLCP grantees to standards for medical exam timeliness. 
In particular, these standards would require clinicians performing 
413(b) examinations, who are affiliated with BLCP clinics, to complete 
initial 413(b) requests within 90 days and 413(b) supplemental medical 
evidence development within 60 days. Additionally, to strengthen the 
quality of services provided by BLCP grantees, HRSA proposes requiring 
medical and non-medical personnel from all BLCP clinics to complete the 
OWCP-sponsored training modules entitled ``Black Lung Disability 
Evaluation and Claims Training for Medical Examiners'' prior to 
applying for BLCP grant funds. HRSA invites public comment on whether 
these requirements are reasonable and attentive approaches to 
strengthening the quality of medical services provided by BLCP 
grantees.

g. Grantee Collaboration

    The current BLCP grantees and applicants are mixed in terms of 
those who are clinically focused and those who are service focused. 
Encouraging grantees to share best practices and provide technical 
assistance to one another could help strengthen the quality of the 
BLCP. Proposed mechanisms for achieving greater collaboration include 
allowing grantees to allocate a portion of their award towards 
providing on-site or remote technical assistance to other clinics and/
or encouraging grantees to participate in a yearly peer learning 
workshop hosted by HRSA. HRSA invites public comment on these 
strategies as well as how the BLCE can play a role in facilitating 
grantee collaboration.

h. Pulmonary Rehabilitation

    The current BLCP grant guidance requires grantees to provide for 
accredited pulmonary rehabilitation services. The first two funding 
tiers require BLCP grantees to provide ``on-site or contracted 
accredited Phase II or Phase III rehabilitation services,'' while the 
third and highest funding tier requires BLCP grantees to provide an 
``on-site'' and ``American Association of Cardiovascular and Pulmonary 
Rehabilitation (AACVPR)-certified'' pulmonary rehabilitation program. 
Current BLCP grantees have expressed concerns that these standards are 
difficult to meet, particularly in rural areas where miners have to 
travel long distances to attend multiple sessions a week. Thus, HRSA 
invites public comment on how to revise the BLCP requirements around 
pulmonary rehabilitation such that they are feasible but still ensure 
that miners receive a variation of this beneficial service.

    Dated: August 15, 2016.
James Macrae,
Acting Administrator.
[FR Doc. 2016-19938 Filed 8-19-16; 8:45 am]
 BILLING CODE 4165-15-P