1	BRIEFING ON THE NOTICE OF PROPOSED RULEMAKING FOR DESIGNATION OF UNDERSERVED AREAS National Association of Rural Health Clinics Technical Assistance Call Rockville, MD March 11, 2008 Captain Andy Jordan U.S. Department of Health and Human Services Health Resources and Services Administration Bureau of Health Professions
2	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
3	Current Uses of Designations (40 Federal Programs) MUA or MUP Required: CHCs FQHC Look-Alikes HPSA Required: NHSC Medicare Incentive Payments HPSA or MUA Required: RHC certification J-1 Visa Physicians - waiver of return-home requirement Health Professions grant program preferences
4	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”
5	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 Increased accuracy for targeting resources Simplification — one method instead of two Outdated designations — MUA/P 1995 and 2006 GAO report criticisms No statutory requirement to update
6	GUIDING PRINCIPLES FOR THE NEW APPROACH Science-based Face validity Low burden Minimal disruption of existing safety net providers Simplicity
7	The THEORY behind the method
8	Model of the Process
9	The Proposed Process in 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.
10	The Process
11	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
12	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
13	Step 3: Adjust Base Ratio for Community Characteristics that Affect Resources Determine effects of factors on communities’ ability to attract primary care resources
14	OTHER HIGH NEED INDICATORS CONSIDERED Level of Uninsured-uniform data not available; highly correlated with 200% poverty 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
15	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 The adjusted ratio reflects unadjusted population to practitioner ratios that are as low as 1,082:1 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 1500:1 It demarcates the lowest quartile of all scores
16	EXAMPLE OF THE METHOD ANYTOWN, USA POPULATION=30,215; PROVIDERS=10.4; Current Unadjusted Ratio: 2905:1 OPTIMAL VISITS USING AGE/GENDER NON-BARRIERED RATES 119,319 EFFECTIVE POPULATION: 119,319/3.741 (AVERAGE NON-BARRIERED RATE) = 31,895 ADJUSTED POPULATION:PROVIDER RATIO: 31,895/10.4 = 3067:1 ADJUSTMENT FOR HIGH NEED INDICATORS: ADDITIONAL NEED FOR CARE BASED ON HEALTH STATUS AND SOCIO-ECONOMIC FACTORS: ADD 1169 “NEED FACTORS” TO 3067:1 RATIO = 4236:1
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18	ADDITIONAL EXAMPLES
19	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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24	TWO TIERED APPROACH WHAT 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 Concern about overestimates of need If federal resources are not counted, are we overestimating need? SOLUTION: - Separate “eligibility” for existing resources from the “targeting of new resources”
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26	IMPACT AT THE STATE LEVEL Regional/State Impact of national testing: Majority of States retain > 80% of current designated areas Areas retaining <80% has more providers, lower poverty, and higher population density-the 3 most powerful factors (mainly NE US) Four states (NC, WA, CA, NY) worked with Regional Workforce Centers to apply the method with their own data; Local data tended to increase the number of designations They were able to use the method They expressed no major concern
27	STATE TESTING RESULTS USING LOCAL DATA WASHINGTON - 91% OF GEOGRAPHIC HPSAS WOULD BE CONTINUED VERSUS 69% WITH NATIONAL DATA NEW YORK – 88.7% VERSUS 58% OF HPSAS; 79% VERSUS 54% OF MUAS; MORE DRAMATIC INCREASES IN UBAN AREAS CALIFORNIA – 174% INCREASE IN HPSAS AND 33% INCREASE IN MUAS USING THEIR SERVICE AREAS AND FEDERAL DATA NORTH CAROLINA – 44% INCREASE IN HPSAS; 34% DECREASE IN MUAS
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29	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 option of being designated base on their user profiles if the area or population designation steps above do not qualify. This should assure minimal disruption of Safety Net Programs.
30	TRANSITION PROCESS Three Year Phase-In from date of final rule in Federal Register 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
31	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
32	TIMELINE FOR FINAL RULE February 5-April 7 ’08 60 Day Comment Period April-August ‘08 HRSA Review , Departmental Clearance, Secretarial Review and Approval Sept–November ’08 OMB Clearance of Final Rule Dec ’08/January ’09 Final Rule Published January ’09 Transition Period Begins
33	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
34	FOR FURTHER INFORMATION Andy Jordan Chief, Shortage Designation Branch OWEQA, BHPR Room 8C-26 Parklawn Building 5600 Fishers Lane Rockville, MD 20857 301 594-0816 ajordan@hrsa.gov 1-800-400-2742 www.bhpr.hrsa.gov