BRIEFING ON THE NOTICE OF PROPOSED RULEMAKING

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BRIEFING ON THE NOTICE OF PROPOSED RULEMAKING

• Bureau of Primary Health Care
• All Grantees Meeting
• Washington, DC
• June 24, 2008
• Captain Andy Jordan
• U.S. Department of Health and Human Services
• Health Resources and Services Administration
• Bureau of Health Professions

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DESIGNATION HISTORY

• Designations started in 1970s to support 2
  programs
• HPSAs for the National Health Service Corps
  (NHSC)
• MUA/Ps first for the HMO program and then for the
  Community and Migrant Health Center program
• In the 1980s, 2 major CMS programs added
• Rural Health Clinic (RHC) certification for
  clinics in HPSAs or MUAs
• Medicare Incentive Program for physicians
  delivering services in HPSAs (10 additional
  payment)
• Currently
• 40 Federal Programs use designations, as well as
  State and other programs, including CHCs, FQHC
  Look-a-likes, NHSC

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Current Uses of Designations (40 Federal
Programs)

• HPSA or MUA Required
• RHC certification
• J-1 Visa Physicians - waiver of return-home
  requirement
• Health Professions grant program preferences

• MUA or MUP Required
• CHCs
• FQHC Look-Alikes
• HPSA Required
• NHSC
• Medicare Incentive Payments

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MAJOR CRITICISMS OF THE EXISTING METHODS

• CREATE ONE PROCESS-CONFUSING AND BURDENSOME
• FAILURE TO INCLUDE NP/PA/CNM IN PROVIDER
  COUNTS
• CURRENT HIGH NEED INDICATORS NOT SUFFICIENT TO
  CAPTURE REAL ACCESS ISSUES
• MUAS WERE NOT REQUIRED TO BE UPDATED SOME ARE
  OVER 20 YEARS OLD
• CONCERN THAT CURRENT METHODS DO NOT REFLECT TRUE
  NEED
• CONCERN THAT COUNTING OF RESOURCES TARGETED AT
  AREAS OF NEED MAY MAKE THE AREAS INELIGIBLE FOR
  THESE RESOURCES-Yo-Yo

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WHY DO WE NEED A NEW METHOD?

• Increased accuracy for targeting resources
• Simplification one method instead of two
• Outdated designations MUA/P
• 1995 and 2006 GAO report criticisms

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GUIDING PRINCIPLES FOR THE NEW APPROACH

• Science-based
• Face validity
• Low burden
• Minimal disruption of existing safety net
  providers
• Simplicity

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The THEORY behind the method
This can be measured in primary care visits
1. Access is the appropriate use of health care
services 2. Multiple factors create barriers to
that use, demand is decreased 3. Those factors
and others result in greater need, demand is
increased
This is evidenced by a lower visit rate
This is partly reflected in a higher use rate
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The Proposed Processin Steps

• Adjust population to account for biological
  need.
• Count practitioners and create a ratio to
  adjusted population.
• Create community weights for barriers and need,
  add to adjusted population.
• Compare to standard.
• Remove federal practitioners from ratio (to
  address the Yo-Yo effect issue)
• Compare to standard.

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Calculation StepsGEOGRAPHIC AREAS CAN BE
REPEATED FOR POPULATION GROUPS
The Formula
Identify area
Adjusted PopulationPractitioner Ratio
Adjust for Ageand Gender Utilization

Need/Barrier Scores

Adjust for BarrierFactors
Tier 1 Geographic Score
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Step 1 Estimate Barrier Free Population Use
Rate

• Calculate the utilization of the population as if
  they had no barriers
• Adjusted for age and gender
• Applied to actual area age-gender total

From MEPS 1996
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Step 2 Determine Base Population to Practitioner
Ratio

• Primary care providers include MDs, DOs, medical
  residents, PAs, NPs, and CNMs
• Use FTEs, adjusted by weighting medical residents
  at 0.1 and PAs, NPs, CNMs at 0.5 and based on
  state scope of practice law
• Allow for local adjustment of FTEs to reflect
  actual practice

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Step 3 Adjust Base Ratio for Community
Characteristics that Affect Resources

• Determine effects of factors on communities
  ability to attract primary care resources

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OTHER HIGH NEED INDICATORS CONSIDERED

• Level of Uninsured-uniform data not available
  highly correlated with 200poverty and
  unemployment
• Changes in Income, Educational Levels,
  Employment in various sectors-highly
  intercorrelated with each other and with poverty
• Few variables for which these are not proxies
• Final decisions based on greatest impact,
  independence from other variables, and data
  availability and stability over time

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Step 4 Determine if Adjusted Ratio Exceeds
Threshold

• The adjusted ratio is the combination of the
  effective population and the community need and
  use factors and is a SCORE
• It compares the need for care to the capacity of
  to provide it
• A benchmark score of 3000 is used because it
  aligns with prior ratio estimates of perceived
  need
• It can be interpreted as Two times the
  sufficient ratio of 15001
• It demarcates the lowest quartile of all scores

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EXAMPLE OF THE METHOD

• ANYTOWN, USA
• POPULATION30,215 PROVIDERS10.4 Current
  Unadjusted Ratio
• 29051
• OPTIMAL VISITS USING AGE/GENDER NON-BARRIERED
  RATES
• 
  
  119,319
• EFFECTIVE POPULATION 119,319/3.741 (AVERAGE
  NON-BARRIERED RATE)
  
  31,895
• ADJUSTED POPULATIONPROVIDER RATIO 31,895/10.4
  30671
• ADJUSTMENT FOR HIGH NEED INDICATORS ADDITIONAL
  NEED FOR CARE BASED ON HEALTH STATUS AND
  SOCIO-ECONOMIC FACTORS ADD 1169 NEED FACTORS
  TO 30671 RATIO
• 
  
  42361

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Examples from North Carolina
Score
Barrier-free
used to
Tier 1
Designated
County
Type of HPSA
Total
adjusted
Total
Base
adjust
Adjusted
under
Name
Designation in 1999
Population
population
providers
ratio
ratio
SCORE
NPRM2?
Anson
whole cnty HPSA
24222
28966.2
9.6
3017.3
1110.0
4127.3
yes
Clay
whole cnty HPSA
8403
10484.6
3.5
3039.0
834.4
3873.4
yes
Halifax
low-inc pop HPSA
57397
67275.2
38.6
1744.0
1485.2
3229.2
yes
Johnston
cnty has no HPSA
103302
121525.9
45.6
2667.2
585.6
3252.9
yes
Caldwell
part cnty geog HPSA
5437
6360.2
3.0
2120.1
659.2
2779.3
no
Durham
cnty has no HPSA
200842
231803.1
408.0
568.2
484.7
1052.8
no
Halifax County goes from 1,744 to 3,229 and is
designatable
Durham County goes from 568 to 1,053
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ADDITIONAL EXAMPLES
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IMPACT TESTING

• RESULTS MEASURED COMPARING NUMBER OF AND
  POPULATION OF HPSAS/MUAS WITH CURRENT/NPRM1 AND
  NPRM2
• COMPARING EFFECT ACROSS CHCS/NHSC/RHC PROGRAMS
• COMPARING METRO/NON-METRO/FRONTIER

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(No Transcript)
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IMPACT ON NUMBER OF DESIGNATIONS
METRO/NON-METRO, AND FRONTIER AREAS
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IMPACT ON DESIGNATED POPULATION, IN MILLIONS
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IMPACT ON SAFETY NET PROVIDERS CHC/NHSC/RHC
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TWO-TIERED APPROACHWHAT IS IT, AND WHY?

• Concern about the Yo-Yo effect
• If federal resources are counted, many areas
  where they exist would no longer be eligible and
  would lose them

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IMPACT OF THE TWO- TIERED APPROACH TO COUNTING
PROVIDERS
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STATE TESTING RESULTSUSING LOCAL DATA

• Nearly 40 states have conducted at least a
  partial analysis of the new method using local
  data
• All report significantly higher retention of
  existing designations and designation of new
  areas when local data are used
• Limited impact on safety net programs when Safety
  Net Facility option is included

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IMPLEMENTATION-THREE-STEP PROCESS

• STEP 1 NATIONAL DATA CALCULATIONS FOR
  GEOGRAPHIC AREAS
• Majority of areas would qualify with no further
  steps necessary particularly rural and frontier
  areas.
• STEP 2 SUBMISSION OF LOCAL DATA AND POPULATION
  GROUP DATA
• Areas not qualifying in Step 1 may submit more
  updated or more accurate data or define a
  different area or population for analysis most
  likely for sub-county and urban areas.
  Additional areas will qualify once this step is
  completed.
• STEP 3 SAFETY NET FACILITY OPTION
• Finally, Safety Net Facilities (FQHCS, etc.)
  have the opportunity to be designated based on
  their user profiles if the area or population
  designation steps above do not qualify. This is
  intended to assure minimal disruption of Safety
  Net Programs.

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TRANSITION PROCESS

• Three-Year Phase-In from effective date of final
  rule
• Probably oldest MUA/Ps and HPSAs reviewed first
• Listing of current areas with the computed ratios
  distributed to states
• 90-day comment period for states regarding area
  boundaries, accuracy of data, etc.
• Publication of approved areas after comment
  period and review

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A Tool for Defining Areas for Analysis

• NPRM includes reference to the Primary Care
  Service Area (PCSA) as one way of helping define
  logical service areas
• States may want to consider these as a starting
  point if they wish to develop a statewide service
  area plan
• Following speaker will address how the PCSAs were
  developed and can be used

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DID WE MEET OUR OBJECTIVES?

• ISSUES RESPONSE_____
• NP/PA/CNM INCLUDED
• ASSESS HIGH NEED NEW VARIABLES USED
  INDICATOR PER CONSENSUS
• CREATE ONE PROCESS DONE
• UPDATES MUAS WILL DO
• SIMPLIFIED/REDUCE WILL ALLOW NATIONAL
• BURDEN DATA ANALYSIS
  
• INCREASED ACCURACY/ SCIENTIFIC BASIS/
• IMPROVED TARGETING MORE AREA SPECIFIC
• NEED DATA
• BACKOUT NHSC/CHC/J1 INCORPORATES

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SUMMARY

• Only One method Streamlined procedures at the
  State and Federal level increased use of
  technology
• Improved ability to target resources
• Major criticisms addressed
• Improved scientific foundation
• Involvement of stakeholders increases buy-in
• Extensive impact testing shows minimal negative
  impact

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CURRENT STATUS

• Comment period extended through June 30, 2008
• Close to 500 Comments to be reviewed and revised
  rule with response to comments forwarded for
  clearance
• After publication, six month delay pending
  Congressional review
• Three year implementation period

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FOR FURTHER INFORMATION

• Andy Jordan
• Director, Office of Shortage Designation
• BHPR
• Room 8C-26 Parklawn Building
• 5600 Fishers Lane
• Rockville, MD 20857
• 301 594-0816
• ajordan_at_hrsa.gov
• 1-800-400-2742
• www.bhpr.hrsa.gov