FLORIDA SOCIETY OF PHYSICAL MEDICINE AND REHABILITATION

Minutes
May 11,2007
JW Marriott Buckhead, Atlanta, GA

FLORIDA SOCIETY OF PHYSICAL MEDICINE AND REHABILITATION

April 30, 2006
Doubletree Grand Hotel, Miami

MINUTES 

Presiding:  Enrique Monasterio, MD, President 

Present in order of sign-in:  Anthony Dorto, MD, Enrique Monasterio MD, Ibiza Vevares MD, Rodolfo Eichberg MD, Mitchell Freed MD, Robert Christopher MD, Dorothea Glass MD, Duby Avila MD, Craig Lichtblau MD, Arthur Pasach MD, Lorry Davis Executive Director.  Guests:  William Fleming MD, Xinmin Tang MD, Penniford Justice MD, Ann Crutchfield, Practice Administrator for Dr Eichberg et al. 

Old Business: 

1. Minutes of the July 30, 2005, Orlando Meeting were approved – Dr Duby Avila, Secretary 

2. Membership Report – Dorothea Glass MD, Past President

We currently have 119 members, 12 of whom are retired, hence 107 dues paying members.  We again employed AAPMR to send FSPMR member apps, along with AAPMR dues notices, to those AAPMR members in FL who are not yet FSPMR members.  From this, we netted 4 new member applications.  The cost was $101.39.  We will engage in this process again for 2007. 

Today we consider 4 candidates for membership:

 A motion was made and carried to accept these candidates as members in the FL Society of PM&R. 

Also recommended for membership:

Harold L Dalton DO, Ft Lauderdale                           recommended by             Lee Ann Brown DO 

A motion was made and carried to accept Dr Dalton as a member in FSPMR. 

3.  Treasury Report – Dr Monasterio - Specific information on the Treasury Report can be obtained by members from Lorry S. Davis, Executive Director, PO Box 330298, Atlantic Beach FL  32233-0298, Ph 904 270 8886, Fax 904 246 9233, Lorry4@earthlink.net  

4.  USF Residency Program:  Dr Xinmin Tang reported that for the first three years, the PM&R Residency Program at USF has not been accredited.  This year, the program has been approved.  There is a faculty deficiency including the Chair.  Dr Tang asked for more involvement from FSPMR physicians.  Dr Eichberg’s group is involved through Tampa General Hospital and the Tampa VA. 

New Business: 

1.  PMR’s Non-Eligibility for Pediatric Medicaid Fee Increases:  The FMA is going to help us follow up to get a response from Alan Levine, Secretary for AHCA, to the letter from us of May 4, 2006:  “We are respectfully requesting that the specialty of Physical Medicine and Rehabilitation, an American Board of Medical Specialties (ABMS) recognized specialty, be added to the list of specialties included on the Medicaid Pediatric specialty fee increases, which was promulgated in 2004. 

Paul Kornberg, MD, FAAP, FAAPMR, an FSPMR member, writes that he recently received the following email from a pediatric listserv regarding Medicaid payment increases approved by the Governor –“$124.8 million to fund Medicaid rate increases for physicians, dentists and other healthcare providers. The proposal will increase rates for pediatric specialty physician services and dental services as well as supporting primary care services that focus on prevention and early identification of chronic illness.  Governor Bush and Lt. Governor Jennings are also recommending increases for home-health visits and non-emergency transportation services...." 

Further, Dr Kornberg writes, “The state level administration is unaware of the lack of access to the field [physical medicine and rehabilitation] because it is so under-represented in Florida.  There are no other providers providing my services on the west coast of Florida.  There are less than a handful scattered through the state (mostly in south Florida).  A change in Medicaid payments will have a direct impact (in my situation) to access to care for pediatric patients in need of rehabilitation specialists.”  

What other information can we provide you to help make it possible for Physical Medicine and Rehabilitation to be added to the list of pediatric specialties included on the Medicaid Pediatric specialty fee increases?  Thank you for your consideration and assistance. 

2.  AAPMR NCMRR Initiative:  A motion was made and carried to send a letter from the society as a whole and to encourage individual members to send letters themselves, regarding elevating the National Center for Medical Rehabilitation Research at the NIH to an independent Institute or free-standing Center.  An email/fax re same will go to all members.

3. Outgoing President, Dr Monasterio, stated it was an honor to serve the Society these past two years.  A special plaque was presented to Dr Monasterio by Dr Freed.

4. Slate of Candidates for 2006 – 2008:  Dr Freed, Nominating Committee Chair. Congratulations to our new Officers.  The following slate was elected by acclamation:

President:  Venerando Batas MD

VP:  Robert Dehgan MD

Secretary:  John Muenz MD

Treasurer:  Ruby Avila MD

Members at Large:

Rigoberto Puente MD, Mark Rubenstein MD, Mitchell Freed MD 

Good and Welfare: 

1. Dr Robert Christopher, on the Editorial Board for the Archives of PM&R, informed us of a fundamental change to that publication.  In 2007, ownership of the journal will go back to the ACRM.  It is now ½ and ½ with AAPM&R.  The AAPM&R Board voted to start a new journal.

2. A motion was made and carried that FSPMR’s 2007 annual meeting will be in conjunction with the SSPMR annual meeting, spring, 2007, in Atlanta.

3. Dr Fleming led a reminiscence of “the old PM&R days” both here in FL and throughout the South, discussing the origins and early days of PM&R residency programs.  Participating in this reminiscence with Dr Fleming were Drs Christopher, Pasach, Glass, and Eichberg.  Dr Fleming brought a (carbon) copy of a letter he had written to George C Cunningham MD, Palm Beach, Florida, dated July 16, 1964.  Dr Pasach was one of the physicians cc’d on this letter.  These discussion participants are invited to write down their reminiscences and give them to FSPMR’s Executive Director for placement in the FSPMR history portion of our website.

Respectfully submitted,  

Lorry S. Davis, M.Ed., Executive Director        

July 30, 2005

Gaylord Palms Resort & Convention Center

7 - 9 pm 

MINUTES 

Many thanks to ALLERGAN for their support of this meeting. 

Presiding:  Enrique Monasterio, MD, President 

Present in order of sign-in:  Ronald Tolchin DO, Jesse Lipnick MD, Robert B Dehgan MD, Lance Cassell MD, Geeta Narula MD, Michael Creamer DO, Mitchell Freed MD, Paulette Smart-Mackey MD, D Paul Harries MD (GUEST), Dorothea Glass MD, Enrique Monasterio MD, Tony Dorto MD, Josephine Estampador-Tan MD, Victoria Rabe-Tagala MD, Ibiza Nevares MD, Duby Avila MD/FSPMR Secretary, Lorry Davis Executive Director 

Old Business: 

1. Minutes of the August 24, 2004, Orlando Meeting were approved –

Dr Duby Avila, Secretary 

2. Membership Report – Dorothea Glass MD, Past President

We currently have 123 members, 11 of whom are retired.  We again employed AAPMR to send FSPMR member apps, along with AAPMR dues notices, to those AAPMR members in FL who are not yet FSPMR members.  From this, we netted 6 new member applications.  The cost was $142.11.  We will engage in this process again for 2006. 

7 candidates approved for membership:                        recommended by

Ramon L Cuevas MD               West Palm Beach         Enrique Monasterio MD

Jose M De la Torre MD           Temple Terrace            Venerando Batas MD

Ariel A Inocentes MD              Hollywood                   Venerando Batas MD

Arthur J Keating Jr MD            Tamarac                       Senior Member

Nnamdi Nwaogwugwu MD      Orlando                        Michael Creamer DO

Zoraya Parrilla MD                   Miami                           Ronald Tolchin DO

Roberto Perez-Millan MD        Tampa                          Venerando Batas MD 

There are 3 prospective members who have inquired, been sent applications, but have not as yet completed them:  They are Drs Powel Crosley, Harold Dalton, and Jeffrey Farber.  Dr Lance Cassell will follow up with Dr Crosley.  If you know the other two, please encourage them to complete their applications. 

Lastly, we’ve lost track of 2 members:  Drs Nicholas Cherup (was in Sun City Center) and Lelia Sterescu (was in Tampa).  If any of you know of their current whereabouts, please inform Lorry Davis, 904 270 8886, Lorry4@earthlink.net. 

3.  Treasury Report – Dr Monasterio - Specific information on the Treasury Report can be obtained by members from Lorry S. Davis, Executive Director, PO Box 330298, Atlantic Beach FL  32233-0298, Ph 904 270 8886, Fax 904 246 9233, Lorry4@earthlink.net  

4.  Medicare Report – Robert Dehgan MD gave the report of Dr Colleen Zittel MD, CAC Rep, who was unable to attend this meeting – She attended the Medicare CAC Meeting

Sat June 18^th, Embassy Suites Hotel, Orlando, and this report follows: 

LCD on Computerized Dynamic Posturography (CDP)-92548

CDP is currently non-covered my Florida Medicare.  A draft policy was looked at during this meeting, after multiple letters were sent to Florida Medicare in support of coverage, by multiple university movement disorder clinics, the APTA, local hospitals/ PT's, and other sources.  The policy looks fine except for the fact that it only allows testing once per beneficiary- we are working through the committee on changing it to at least two or three allowed tests per patient.  We will work on language to include in the policy to avoid overutilization, ie, to prevent nursing homes, CORF's and other entities from falling into the trap of testing every single patient with CDP, since almost all elderly have some balance deficit or occasionally fall, but not all of those need CDP.  The policy may be discussed again at the next meeting in 4 months, if not finalized.  To view policy, look up  www.floridamedicare.com, part B, medical policy, draft, pull up by policy #92548.  I'd like your comments on this before we submit it for finalization (comment period ends on 7-18-05). 

Thanks to the persistence and hard work of Andrea Trescot, MD, (Anesthesiologist, on CAC representing the FMA), a change request has been finally approved, and now, Interventional Pain Management will have its own designated seat or position on the CAC.  This is in addition to a seat for FL Soc of Anesthesiologists.  Good work! 

CMS Announces the National Provider Identifier (NPI)

This will be a new "health care identifier" for use in the HIPAA standard transactions, an identifier # for all health care providers, health care groups, etc.  You can begin to apply for your NPI beginning May 23, 2005..  Compliance date is May 2007.  For more info on this & how to apply, www.cms.hhs.gov/medlearn/matters, and look up letter titled SE0528, or, https://nppes.cms.hhs.gov 

James Corcoran, Contractor Medical Director, gave an update on Medicare Modernization Act of 2003.  Familiarize yourself with the Medicare Prescription Drug Benefit- your patients will be turning to you for info on this. (partners web site:  www.cms.hhs.gov  , or ,www.medicare.gov as a beneficiary-friendly website.  Also, Medicare is going to restructure, from nationally, a large # of Fiscal Intermediaries and Carriers, into a much smaller # of entities, integrating Part A & Part B into a single authority, Medicare Administrative Contractor (MACs), arranged by region within the US.  CAC committee has not been commented on but will probably (?) stay. 

Dr Zittel’s Letter Dated July 17, 2005

To: Cindy Howard RN

Medical Policy @ FCSO 

Dear Cindy, 

I have taken some time to gather information from my colleagues regarding potential changes to the Computerized Dynamic Posturography policy. The following comments are responses to questions and concerns raised at the June 18, 2005 CAC meeting. 

Documentation Requirements

In order to prevent abuse by nursing homes, which could potentially test every patient, we suggest that the following be placed in the documentation requirements: 

(after second sentence beginning "medical necessity for providing the service...")

 "It should be documented that this test is being done as part of a provider- initiated workup for chronic unexplained disequilibrium, vertigo or dizziness.  It is expected that this test would be performed as part of an organized balance and/or fall prevention program."   

"The medical record should also document the patient's general cognitive status.  That is, the patient must be able to understand and follow commands, in order to learn appropriate habituation and compensatory strategies.  It is not expected that patients with severe or advanced dementia would undergo CDP testing."   

 Utilization Guidelines 

We have not been able to find any specific literature or research articles documenting the "correct" or appropriate number of CDP tests for a given patient.  However, it is strongly suggested by physiatrists, balance P.T's and neuro-otologists who commonly utilize this test, that a minimum of two tests be allowed per patient.  They do suggest that testing at each reassessment (1 time per month per Medicare patients), during their course of rehabilitation,  would be ideal.  Therefore, we suggest the following wording: 

"It is expected that these services would not generally be performed more than twice for a clinical indication.  An initial study is allowed, and then a second study may be allowed only if needed to alter or direct the treatment regimen.  Documentation must be provided as to how this second testing is expected to direct or alter the treatment regimen.  In more involved cases, more testing may be required, and therefore documentation must be provided for additional clinical circumstances.  Additional cases would be subject to review for medical necessity." 

Thank you for allowing us the opportunity to work with you on this policy.

Please let me know what you think of these suggestions, and let me know if you have any questions or concerns I can answer. 

Thank you! 

Colleen Zittel MD

CAC Rep, FL Society of Physical Medicine & Rehabilitation 

Dear FSPMR members (dated July 18, 2005)

To preserve inpatient rehabilitation as we know it, we need your help.  The proposed Florida Medicare LCD on Inpatient Rehabilitation, along with its "75% rule", will severely limit which patients we can admit to inpatient rehabilitation.  This will dramatically alter many of our practices,  the very existence of certain rehab units, and the well being of our patients.  If you have not already contacted Florida Medicare/ First Coast Service Options (FCSO) regarding this matter, we are asking that you contact them with an email of support / endorsement of the consensus letter prepared by Dr Freed.  Although you have probably already received a copy of this letter, (recently distributed by email to the FSPMR membership), the letter is again provided as an attachment for you.  We need each and every one of you to individually contact FCSO with your support for FSPMR's letter, regardless of whether or not you currently practice inpatient rehabilitation.  Every Florida physiatrist's voice should be heard.  Please feel free to provide any comments or concerns you may have regarding how this policy will impact your own practice.  You can contact FCSO at medical.policy@fcso.com.   Thank you to all who have worked very hard on this policy, those of you have already contacted FCSO, and thanks to the rest of you for joining forces with us now. 

Sincerely, 

Colleen Zittel MD

Florida Medicare Carrier Advisory Committee Representative for FSPMR   

New Business:

1. FSPMR Response to Proposed Medicare LCD (Local Coverage Determination)

 on Inpatient Rehabilitation

Preserving Inpatient Rehabilitation - Mitchell Freed MD, Past President

Others involved in this effort to date: 

Drs Alan Novick, Ibiza Nevares, Colleen Zittel, Venerando Batas,

Justine Vaughen, David Lipkin, Mark Rubenstein, Karen Williams, Brad Ain

July 14, 2005

Medical Policy and Procedures Dept.
First Coast Service Options                                             
PO Box 2078
Jacksonville, FL 32232-0048 

Mitchell J Freed MD
2501 N Orange Ave.  #505
Orlando, FL 32804
 

Re: Draft LCD for AIRF Inpatient Rehabilitation 

Attention: Jim Corcoran MD, Cindy Howard, Susan Gladora 

Thank you for the open forum phone conference with Physicians providing rehabilitation in Inpatient Rehabilitation facilities in Florida including many of us from the Florida Society of Physical Medicine and Rehabilitation.

In your task as a fiscal intermediary charged with responsibility for medical reviews, it is reassuring to see the common goal of providing appropriate patients, access to In-patient Rehabilitation Facilities and clarifying CMS guidelines in the form of LCD policy.

(Note: CMS policy is italicized as in the LCD.) 

As stated by CMS: “Physicians generally agree on the circumstances that justify a medical or surgical patient’s hospitalization.  In addition, some cases an admission to a rehabilitation hospital or to the rehabilitation service of a short-term hospital can be justified on essentially the same medical or surgical grounds.  In other cases a patient’s medical or surgical needs alone may not warrant inpatient hospital care, but hospitalization may nevertheless be necessary because of the patient’s need for rehabilitative services”.   

As outlined by CMS, medical necessity is based upon the patient’s need for intensive rehabilitation services due to impairment in Function and supported by the need for 24 hour availability of a RN with specialized training or experience in rehabilitation and close medical supervision by a Physician with specialized training or experience in Rehabilitation. 

The purpose of Inpatient Rehabilitation admissions is to address a patient’s functional deficits (primarily inability to transfer, ambulate, take care of self care needs, communicate needs, swallow safely, return immediately to independent functioning at home) with the use of an intensive comprehensive rehabilitation hospital team approach.  This is NOT skilled therapy at a nursing home and NOT an acute hospitalization for medical issues. The “medical necessity” addresses providing the optimal environment for maximizing return of function. The goals addressed on a rehab unit require “medical stability” and 24 hour Rehab nursing care and Rehab physician availability (not med/surg nurses or internal medicine/surgical physicians) to allow full benefit from therapies and cannot be accomplished in an alternative setting. 

In reviewing the LCD, we have difficulty with Limitations, bullet 7….  “Although all admissions must meet medical necessity and requires intensive inpatient rehabilitation, “routine admissions for simple fractures, simple joint replacements…would not be expected” (These are all diagnoses within the 21 REHAB IMPAIRMENT CATEGORIES and 105 CMGs).  Then…”However when such an admission meets the coverage criteria, careful attention to documentation as to why the patient requires intensive inpatient rehabilitation should be present…this should emphasize co-morbidities and the intensity of the underlying condition”.  

We believe this goes against the intent of CMS by supposing limitations and therefore, possible limitation of service based on diagnostic screens, diagnosis or specific treatment norms.  We understand that all diagnoses require documentation of medical necessity. 

As stated by CMS: “Medicare recognizes that determinations of whether hospital stays for rehabilitation services are reasonable and necessary must be based on an assessment of each beneficiary’s individual care needs. Therefore, denials of services based on utilization screens, numerical screens, diagnosis or specific treatment norms, “the three hour rule,” or any other rules of thumb,” are not appropriate. 

We respectfully request the removal of limitations bullet 7 and encourage statements regarding the necessity for inpatient rehabilitation be based upon documentation of each individual’s functional impairment and need for intensive comprehensive rehabilitation services. Clarification of the definition of need for a Rehab physician availability and 24 hour rehab nursing should state: there is documentation of the underlying condition, co-morbid conditions or complications that require frequent rehabilitation physician monitoring or treatment changes such that it would be impractical or unreasonable to perform this at a lesser intensity of care such as SNF or Home. This would include documentation of the need for  continuing availability of a Rehab physician and 24 hour Rehab nursing to ensure safe and effective treatment. 

Another area of concern was Team Conference Documentation (p9) and statement that:

 “It is at the team meeting that each discipline summarizes…” 

As agreed during the conference call, the wording should be changed to reflect the intent that there is a summary of the patient’s progress toward goals, any change in goals and any change in discharge planning. Current wording suggests that an extensive note by each treating therapist should be done at each team meeting.  This would require an excessive amount of redundant paper work, and it was agreed upon that this was not the intent of the statement. 

An additional point we want to emphasize is our view that review of Rehab hospitalizations should include Rehabilitation Professionals! Again, this is not a medical or surgical admission. 

I am including with this letter for your information a recent article documenting the improved outcome and function, length of stay efficiency and cost effectiveness of hip fracture patients going to IRF as opposed to SNF.  "Effect of Rehabilitation Site on Functional Recovery After Hip Fracture" published in Archives of PM&R, pp 367-372 in Vol 86, March 2005 issue. This should help illustrate the role of IRF for patient’s in one of the “CMS 13” that should not be a limitation based on diagnosis alone. 

Thank you for your consideration, 

Mitchell J. Freed MD, 

Representative for and endorsed by Florida Society of Physical Medicine and Rehabilitation 

2. FMA Specialty Council/Council on Legislation – July 8 – 9, Coral Gables –            FSPMR was represented by Dr Mark Rubenstein.   – Anthony Dorto MD gave Dr Rubenstein’s report:  Dr Rubenstein fails to mention in his report that follows that he provided 2 articles pertinent to the recent LCD on AIRF:

"The Relation Between Therapy Intensity and Outcomes of Rehabilitation in Skilled Nursing Facilities" published in the Archives of PM&R, Vol 86, March 2005 pp. 373-379.

 "Effect of Rehabilitation Site on Functional Recovery After Hip Fracture" published in Archives of PM&R, pp 367-372 in Vol 86, March 2005 issue. 

Here is Dr Rubenstein’s report:

I was asked to represent the FSPMR at the above meeting, as our esteemed president was unable to attend.  Specifically, I was asked to attend the Specialty Society meeting, as well as the Council on Legislation. 

The weather (Hurricane Dennis) did hamper attendance at the meeting, but it occurred nonetheless.  Last year’s FMA meeting was cancelled, so the nucleus of leaders felt it important to proceed.  Ironic, isn’t it, that the president presiding this year is DENNIS Agliano, MD!! 

On Friday, July 8^th, I attended the Specialty Society meeting.  Courtesy of Dr. Mitchell Freed, I was prepared with a Draft letter regarding the LCD for Acute in-patient rehabilitation.  At that meeting, I discussed the 75% rule and its effect on physiatrists, orthopedists, and other physicians whose patients could benefit from in-patient rehab in an acute setting.  I conveyed the requests of our society regarding wording of the Draft LCD.   

On Saturday, July 9^th, I attended the Council on Legislation meeting.  During the agenda I was invited to make a short presentation, wherein I repeated our request that the FMA support our plight during the 75% rule.  I stressed that this would affect a number of specialties besides PM&R.  I also conveyed our concerns with regard to legislation in the arena of workers’ compensation. 

Support for my presentations was positive, especially from Rick Lentz, MD (Immediate past president of the FMA), Eli Lerner, MD (chair of the Specialty Section), and Larry Gorfine, MD (CAC rep from Anesthesiology and member of the FMA Board of Governors).  Dr. Gorfine suggested that the appropriate place for us to voice concerns about the LCD for AIRF is in the CAC, not at the Board of Governor level.  He is willing to help as our ally, and has had success with these types of issues before.  I would suggest that Dr. Zittel or her successor as the FSPMR CAC rep contact him (office phone 561-649-8770, or via e-mail at LGORFINE@HELPAIN.COM 

Other proceedings of note: 

The Council on Legislation voted to make Expert Witness the #1 legislative agenda priority for the coming sessions.  Sandra Mortham feels that this “may be our last chance to do something about TORT REFORM based on the current house and senate.”  She feels that managed care reimbursement is something that may do better in future years. 

The other legislative issue that the FMA will devote time and $ to is to protect the ability to self insure, since 30% of physicians in Florida currently are. 

FLAMPAC reps stated that 5 million dollars will be needed to accomplish its goals for this year.  They are using the umbrella of “People for a Better Florida.”  They encouraged each physician member of the FMA to join the MD 1000 club ($1000 contribution), by pledging $500 to the People for a Better Florida now, and $500 to a later campaign this year.   

The FSPMR should be advised that we as a society will be asked to contribute money to these concerns. 

Once again, Dr. Gorfine suggested that we use the CAC to gain support of other specialty societies for our issues.   

Respectfully submitted, 

Mark Rubenstein, MD

Member-at-Large, FSPMR  

3.  Dr Zittel Stepping Down as FSPMR’s CAC Rep,  - Dr Robert Dehgan has agreed to replace Dr Zittel and Dr Zittel will stay on as the alternate 

4.  FMA Annual Meeting – September 1 – 4, Boca Raton – FSPMR now has 2 seats

 in the FMA’s House of Delegates, because of the % of FSPMR members who are

 also FMA members.  Drs Monasterio and Batas will be representing us at this meeting.          

5.  AAPM&R Politically Active Enough? – After a healthy discussion of issues such as the DEA’s Interim Policy, the upcoming Medicare Prescription Drug Benefit, and concerns about expanding scopes of practice by nonphysician practitioners, Dr Paul Harries, a visiting physiatrist from out of state, stated he thought that AAPM&R is not politically active enough.  Dr Harries primarily practices pain management and he said a good model for physician political activism was the American Society of Interventional Pain Physicians (asipp.org).  Dr Cassell brought another guest, Basdai Sookoor, RN, who also enlivened our discussions regarding scope of practice issues.   

Good and Welfare: 

1. FSPMR will meet in conjunction with SSPMR’s Annual Meeting, April 38 – 30, 2006, Doubletree Grand Hotel Miami Biscayne Bay.  On Saturday evening, there is a dinner cruise hosted by Dr Craig Lichtblau, SSPMR President, 2005-2006.  Information will be sent to you regarding this meeting.

2.  For those physiatrists interested in interventional procedures, as well as noninterventional pain topics, the Florida Academy of Pain Medicine will hold its annual meeting July 14 – 16, 2006, at The Breakers, Palm Beach.   Information will be sent to you regarding this meeting. 

3.  Dr Tolchin announced that the University of Miami is looking for a PM&R Department Chair for their Residency Program which will be a Co-Residency Program with Nova Southeastern University.  For more information, contact Dr Tolchin, (305) 604-3261, tolchinr@bellsouth.net.

Respectfully submitted, 

Lorry S. Davis, M.Ed., FSPMR Executive Director 

fspmr minutes july 05