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0eca30be-74c0-4f13-aedd-88d4c3c34697.xlsx I. STATUTORY LANGUAGE (HRSA please make any corrections, comments or additions to this section) Blue highlights -- additions 12/10/2010 A. Medically Underserved Area Medically Underserved Population (i) population of an urban or rural area designated by the Secretary as an area with a shortage of personal health services or a population group designated by the Secretary as having a shortage of such services. (ii) include factors indicative of the health status of a population group or residents of an area, the ability of the residents of an area or of a population group to pay for health services and their accessibility to them, and the availability of health professionals to residents of an area or to a population group. B. Health Professional Shortage Areas Based on: Comments/additions 12/10/2010 (1) The ratio of available health manpower to the number of individuals in an area or population group, and Sec 332 B HPSA defined -- R Lee says it refers to: infant mortality (2) Indicators of a need for health services, notwithstanding the supply of health manpower. health status ability to pay Sec 254e is codification -- per Dan access similar -- clear for HPSA re availability -- lumped together in MUA -- four equal pieces. II. COMPONENTS SPELLED OUT IN STATUTE -- with notes accounting for some of the possible interpretations of the components (HRSA please comment and correct -- with caveat that it is not intended that you identify every possible issue or alternative -- however please call attention to important concerns, corrections, additions) A. Population: 1 area residents, non-institutional (institutional has been interpreted as military -- in barracks -- and prison pops); methods have allowed for seasonal residents and tourists 2 population groups -- race, ethnicity, special needs groups 3 can be adjusted/weighted to account for higher use for certain age/sex groups -- or high dependency rates can be used as need indicator 4 can be adjusted per JSI approach for "barrier free" national utilization "norms" (from MEPS) or just for age/sex differences or not at all 5 (race/ethnicity described -- not used as proxy for excess needs at this point) B. Providers: 1 MUA/P: area with shortage of personal health services, or pop having a shortage of such services -- has been shown in terms of providers, not clinics or other services a. primary care providers: MD GP, FP, Int Med (non-specialty), Peds (non-specialty?), OB/Gyn -- none? .4? Other? DO PA -- primary care NP -- primary care scope of practice modifier (state specific)? SPECIALTY more important than "Scope of practice" -- comment of Andrea (and Ron) CNM? count or not? Follow OB/Gyn? Ask them about how they fit into primary care definition -- continuity, comprehensiveness, etc -- include or not? 2 HPSA/P: a. "available health manpower" Bob sees more of a speicalty focus on delivering babies, and prenatal lcare. Marc: as long as NHSC permits CNMs to be placed, shouldn't we count them? Q: for either, what should be considered a SHORTAGE? "old" threshold: 1:3500 or 1:3000 with high need; 1:1500 proposed as SHORTAGE -- before adjustment? C. Factors/Indicators: 1 MUA/P: a. health status mortality, morbidity, risk factors, assets, etc. (HRSA also added elderly ratio and youth ratio to total) b. ability to pay coverage, income levels, language c. accessibility to the services distance? Geographic barriers? Cultural barriers? Transportation availability and cost? Refusal of providers to care for ---disabled, aged, mentally ill, etc. d. availability of health professionals are the providers available to the population? accepting Medicaid and Medicare? (implied: # pop with characteristics that may able to care for disabled? be related to barrier) linguistic and cultural competency? 2 HPSA/P: a. ratio of available health manpower to number of individuals for PC HPSAs/Ps: GP, FP, Int Med (non-specialty), Peds (non-specialty?), OB/Gyn -- none? .4? Other? also PA, NP, CNM? could be same procedure as for MUA/P -- except that AREA definition or population definition may be different. b. "indicators of need for health services NOTWITHSTANDING THE SUPPLY OF HEALTH MANPOWER" not specified -- same factors as for MUA/P have been listed; can also use others -- research efforts (MEPS, BRFFSS, other) show relationships to health outcomes/status can be made into index, or given weights health status readily available: SMR, IMR, LBW, BRFSS self-assessed health status, or other BRFSS/YRBS variables ability to pay accessibility barriers distance? Geographic barriers? Cultural barriers? Transportation availability and cost? Refusal of providers to care for ---disabled, aged, mentally ill, etc. availability of health professionals implies that present may not mean available -- this makes it harder to count for testing impact Other possible measures of NEED: aged -- having trouble getting providers who accept Medicare special populations -- who experience the barriers more than others D. Area: a. HRSA has referred to counties or groups of counties, or other political subdivisions, or other rational service areas, no smaller than census tract. b. Not defined in specific terms in statute c. HRSA has added and developed the RSA (Rational Service Area) concept d. Primary Care Service Area (PCSA) concept has been developed by Dartmouth e. Other definitions have been made and used for various purposes: frontier definition (telehealth), PSAs (Medicare Physician Shortage Areas), etc. Bob Phillips workforce considerations for shortage supply No OB/Gyn for count purposes, but should be eligible for NHSC and other funding that helps them locate in underserved areas. Could discount if kept in. Reason: they don’t provide full scope primary care for full population. Ditto CNMs. No to institutional or federal physicians, because they are not accessible to the full population FTE is desirable, may have to wait on state licensure data to improve Medicaid claims are desirable for the purpose of knowing whether physicians in an area are taking Medicaid patients, not for estimating practice FTE. Not sure if it is viable yet due to Medicare managed care We lack a process for understanding which NPs and PAs are practicing in primary care. AAPA may be best for PAs (they estimate 34%). I recommend a co-location process to assign NP specialty unless other data can be identified. NPs solo or only located with other NPs, NPs in FQHC or RHC, or only located with PCPs should be designated 100% primary care. Those in group practices should be allocated primary care status at the same proportion as the proportion of PCPs in that location. I’m ambivalent about discounting; suggest you look at VA/DOD’s reasoning (on their website). Suggest erring on the side of undercounting since our goal is to assure adequate access—not about their value or professional status. Do include H1B IMGs, Geriatricians, Adolescent med. Do exclude hospitalists Cons for Recommendation re Hours. Provider Pros for including in including in Recommenda-tion re Conditions (direct pt care?) for Type Specialty Subspecialty count count Other comments inclusion Recommendation re adjustment counting toward FTE comments from conference call Friday Dec 17th (others are directly entered in cells) Generally: A- do not count as available capacity institutional or federal physicians (not available to gen'l population); A -- OK --- military, VA, correctinal c - perhaps use low income or B - also federally (NHSC, SLRP) supported (not 40? 35? (excess hours do not count as (insittutional des possible) -- by reg of B. Marc: agrees with not counting them as part of special pops approach -- to necessarily committed to stay); available capacity -- these are a reflection of employment not avail to gen' public. avail capacity but consider them before putting count only those available to C- consider availability to low income, aged, disabled, shortage and need for more providers) -- stay new resources in place -- compute need for them. -- discuss in larger All types… --- --- --- --- minority populations with 40 seems consensus providers -- # -- to advise program -- threshold. group -- MUP issue (Dick -- people placed in CHC -- count or not? Agreement seemed to be around taking them into account - - those receiving direct fed's support are one category, those in settings receiving fed'l " support are another group to be considered re "accessible" -- don't penalize an area for having adjust for part time status; commitments to Marc suggests current approach -- Andy says these services (Eric has ideas about considering J-1 Waivers -- not administration, teaching or research; quite consistently applied -- alice -- the distribution of resources vs maintenance of MDs and DOs --- --- stable capacity? --- --- any adj needed for LTC or Hosp coverage time? local work adds accuracy. designations) many reaching retirement? Will need to continue to survey GP na orig PC providers none re pt care availability include same OK survey re availability; may use Medicaid claims to assess (specialties availability to low income Some have special duties -- consider true Family Practice uncommon) basic PC providers none populations include same available hours OK survey re availability; may use Medicaid claims to assess basic Primary Care availability to low income could be operating as hospitalists -- can be remember definition of primary care -- continuous, Internal Medicine no subspec noted providers none populations include same taken into account in surveys comprehensive survey re availability; may use Medicaid claims to assess NOT basic Primary Care may not do PC -- availability to low income Further: consider if practice is limited to Marc: any subspec -- most cardio docs don't Internal Medicine Cardiology providers need to evaluate populations DO NOT INCLUDE subspecialty deal with other pc services may do considerable PC -- survey re availability; may use but Marc suggest not -- Medicaid claims to assess not "comprehensive generally do not do availability to low income other -- declared -- % continuous chronic and PC -- need to populations -- assume not to case by case basis -- assume Further: consider if practice is limited to Internal Medicine of time in PC? acute care" evaluate include not to include subspecialty survey re availability; may use availability limited Medicaid claims to assess basic Primary Care to children/youth -- availability to low income Pediatrics no subspec noted providers -- for that pop not all ages populations include same Don't inlcude unless evidence shows they are may not do PC -- Further: consider if practice is limited to Pediatrics any subspecialty doing PC don't include don't include case by case basis subspecialty MEPS says <2% get PC from OB/GYN -- variable -- whole Question raised: should we person vs not -- fraction? For find evidence of some % of Don: from designation standpoint not may do some primary impact assessment -- see if it time "on avg" dedicated to helpful to count as PC. Dick: do we know % care -- women do often limited availability -- matters -- and consider leaving PC? 25%? Adjust using of time Ob/Gyns provide PC? Full time or Ob/Gyn all rely on them for PC to women out. survey in implementation? paprt time PC? Surgery? Any surveys? Take care to exclude PC providers who are not doing Primary serving in this capacity (important in impact They do enable PC providers to focus on the Hospitalists none Care exclude testing phase) outpatient care for seniors, may do include -- provided survey primary care, prevention, confirms PC role -- if very and some specialty limited availability -- narrowly practicing, Geriatricians (as FP area of spec?) services to seniors survey practice patterns consider this include -- provided survey confirms PC role -- if very Marc: IM and FP -- geriatricians generally (FP or IM -- area of narrowly practicing, DO meet def of PC -- and do more than just Adolescent Medicine spec?) consider this geriatrics -- suggests counting. Physician Assistants Weighting can be different but consider All PAs pass a PC exam -- who is actually Weighting can be different but consider scope of survey re availability and FTE; scope of duties in diverse settings, and doing PC? PA Assoc has info on their duties in diverse settings, and requirement for MD Family Practice -- Primary AAPA dataset may indicate include -- assume half the visits of MD/DO, so requirement for MD backup. Check on admin supervising physician -- recipe for getting to backup. Check on admin duties for discounting Care basic PC providers level/location of practice include count as equivalent to .5 MD/DO duties for discounting time. PC PA (Dick) from AAPA he will follow up time. Other specialties (ob, surgery, etc.) none not primary care not applicable do not include will be identified by physician Nurse Practitioners Team situations -- NP/PA may be "most survey re availability and FTE; Weighting can be different but consider productive" -- free standing differes -- NP Assoc dataset may indicate include -- assume half the visits of MD/DO, so scope of duties in diverse settings. Be sure to Anfrea suggest count in fulll -- full FTE. Dick: Family Practice basic PC providers level/location of practice include count as equivalent to .5 MD/DO adjust for admin time, other assignments. are we doing designations a favor -- Weighting can be different but consider include -- assume half the visits of MD/DO, so scope of duties in diverse settings. Be sure to Peds or Adult Care basic PC providers include count as equivalent to .5 MD/DO adjust for admin time, other assignments. Consider a default % for PC? 50% or 25% any Cert Nurse Midwife PC prevention as well as care maybe include -- partial? literature or survey work done? (argument that they are prvoided LR thru NHSC) Other acute care -- leave out -- cert exam -- none not primary care not applicable do not include Geriatric -- primarily in institutions -- do not include Others? DRAFT MATRIX FOR POPULATION COUNTS FOR NRMC DATA/TECHNICAL SUBCOMMITTEE BACKGROUND AND/OR DISCUSSION Discussed in Committee 1-7-11, for NRMC 1-17-2011 measurement/reporting issues Populations to count conditions National? State? Local? data sources data source issues (pros, cons) recommended options comments 2000 Census and post decennial 100% count; 2010 census available 6/2011; Use Census 2010 for 2011 and 2012; census estimates American Community Survey (ACS) ACS "controls" won't shift until 2012 or consider state estimates where states including Claritas's resident population national US Census may prove reliable after the so: for short term, those states with propose it; otherwise rely on ACS estimates based on "control" for baseline shifts to 2010 strong estimates programs may find and/or Census estimates (will need Census will no longer be Census their own estimates preferable. review) needed by 2012 for impact analysis -- probably need to use some states may have preferred Census estimates but state State population estimates estimates after census year this is too bad due to the HRSA can accept state estimates for limitations of current service areas if needed estimates institutional populations that have except: other sources of care: US Military (State Military forces not always Demographers FSCPE and US willing/able to supply data -- to military barracks populations Census Bureau work on this -- Census Bureau or State use census group quarters as demographers well as Military data) prison populations (Federal and State - annual updates generally done -- - local prisons that are short term "group quarters" from Census but sometimes just carried over have prisoners served by local or FSCPE year to year -- still OK to use providers) use for facility HPSAs include long term care populations that use the local annual updates generally done -- "group quarters" from Census health services -- generally but sometimes just carried over or FSCPE providers cover community year to year -- still OK to use services as well also include: migrant workers and seasonal count time present in the area -- migrant workers populations accumulate into "person-years" count time present in the area -- seasonal workers accumulate into "person-years" seasonal residents (non-workers, count time present in the area -- such as "snow-birds") accumulate into "person-years" consider duration of stay if measured; tourists if strictly passing through, consider convert to person-years part of day on location Population Characteristics Age Sex Race Language DRAFT MATRIX FOR HEALTH STATUS MEASURES FOR NRMC DATA/TECHNICAL SUBCOMMITTEE BACKGROUND AND/OR DISCUSSION Presented to and discussed by Data Technical Subcommittee 1-7-2011 Health Status Measures sources pros for using cons for using MUA? HPSA? 1. "observed vs. expected" permits comparisons not subject to the must use 5 or 10-year roll-ups for volatility of "age adjusted rates;" Standardized Based on CDC data (froms many small areas; county data Indicator of area's possible Indicator of population's possible 1 available for virtually all counties; mortality ratio (SMR) state VS) must be applied to subcounty unmet need high need 2. takes into account all causes so service areas reflects health status of entire population. must use 5 or 10-year roll-ups for well established indicator of Infant Mortality Rate many small areas; county data Indicator of area's possible Indicator of population's possible 2 CDC (froms state VS) population health status strongly (per 1,000 live births) must be applied to subcounty unmet need high need correlated with SES service areas Post-Neonatal well established indicator of must use 5 or 10-year roll-ups for Mortality Rate population health status strongly many small areas; county data Indicator of area's possible Indicator of population's possible 3 (deaths ages 29 days CDC (froms state VS) correlated with SES -- especially must be applied to subcounty unmet need high need up to one year, per sensitive to availability and adequacy service areas 1,000 live births) of primary care. Black race correlated above and beyond poverty and behaviors (?) indicator of pop health, behavioral but not as strongly correlated with Low birth weight (% risk factors, and SES; also high rate mortality for black race infants; Indicator of area's possible Indicator of population's possible 4 CDC (froms state VS) of live births) indicates need for PC services; OK for certain race/cultrual groups have unmet need high need single year data. more normal birth weights but still have high risk of poor health status. % Fair/Poor Self- perceived health status measure BRFSS -- regional, sometimes Indicator of area's possible Indicator of population's possible 5 Assessed Health likely to be related to perceived or data lag; adults only county level unmet need high need Status (age adjusted) actual need for care Hypertension BRFSS -- regional, sometimes Common problem, can be measured county or regional level, adults Indicator of area's possible Indicator of population's possible 6 prevalence (% of county level even in small areas only, race biased unmet need high need adults) SES related -- due to health BRFSS -- regional, sometimes Common problem, can be measured Indicator of area's possible Indicator of population's possible 7 Diabetes prevalence behaviors or access to care not county level even in small areas unmet need high need easy to distinguish Urban bias -- at least some disabled people tend to live Disability prevalence BRFSS -- regional, sometimes Common problem, can be measured Indicator of area's possible Indicator of population's possible 8 where services may be available; (% of pop >5 years) county level even in small areas unmet need high need self-report may be culturally affected; Less meaningful measure in frontier, island, rural and even some inner city areas -- two offsetting reasons -- patients may be seen in clinics for acute Ambulatory Care H-CUP/AHRQ for those states indicator of potential benefit related situations and not have Indicator of area's possible Indicator of population's possible 9 Sensitive Conditions reporting; Hospital discharge to better primary care to prevent opportunity to appear in hospital -- unmet need high need Hospitalizations data available from others hospitalizations depressing ACS admit rates -- or cases may be admitted due to distance/challenges with discharging a patient -- increasing ACS admit rates. - this is one socio-economic status AJR does NOT recommend its use: 1. index that has been based on cluster - selected variables need to be Graham Center uses multiple inputs -- validity and current status analysis of the selected variables reassessed and practicality and Indicator of area's possible Social Deprivation data sources -- uses questioned; 2. factor analysis is not associated with health status; validity checked; unmet need -- proposed Index composite of unadjusted poverty rate Indicator of population's possible transparent; 3. "index" is not 10 it is an approach based on weights '- direct measures of health status version includes pop:provider black, poverty rate, (Census 2000?), uninsured high need adjustable to actual known conditions associated with selected variables to and SES measures are in fact as ratio so it purports to be all- uninsured, etc. (CPS?), % black (2000 in a place (may be fine for international identify areas expected to be available as the SDI proxies, for inclusive Census?), etc. comparisons or analysis -- not for underserved, without direct health same geographic areas prediction) status measures DRAFT MATRIX FOR SOCIO-ECONOMIC AND DEMOGRAPHIC CHARACTERISTICS FOR NRMC DATA/TECHNICAL SUBCOMMITTEE BACKGROUND AND/OR DISCUSSION Presented to Data Technical Subcommittee 1-7-2011 but not discussed Barriers/Socio- Economic Status Reflection of… conditions National? State? Local? data sources data source issues measurement/reporting issues Measures (pros, cons) recommended options comments Use population under an ACS data not yet controlled to new amount in an area to be census; will be lagging (based for designated, with adjustment Typical use of Census long form (last poverty thresholds currently used smaller places on 5-year roll-up of Does depend on ESRD and/or BLS for cost of living: have to financial barriers to obtaining available 2000) data, for % below are for the lower 48 states, with survey data); does provide for much continuing the work; generally will apply "Poverty" combine ACS data on income primary care poverty threshold (or for low income, adjusted thresholds for AK & HI -- more local information colleted in only to non-insitutional resident levels of households with an below 200%) but not sensitive to cost of living standard way; can be used to populatin; in implementation will likely recommend using the ESRD adjustment using BLS and/or determine rate or number of people require better accounting for other calculations for the area for the level of ESRD (Dept of Agriculture) affected/at risk populations -- may have to request interest, and ACS data to estimate the adjustments evidence of details of this population. population actually below that level Use ESRD calculator ACS data not yet controlled to new census; will be lagging (based for Alternative to Americal Community Survey With ACS 5 year roll-up data can smaller places on 5-year roll-up of "poverty" - Cost of financial barriers to obtaining household income distribution can be be applied even to community survey data); does provide for much Living Adnusted primary care adjusted using one of several level -- using regional COLAs (from more local information colleted in Poverty methods for COLA BLS, USDA or related sources) standard way; can be used to determine rate or number of people affected/at risk health reform is expected to reduce this; some forms CPS and BRFSS (and SAHIE modelled no health coverage (at this national gov sources only (BRFSS counted as coverage are validation of new sources still Uninsured estimates) have been sources but not time?) per ACS not robust at service area level) minimal (VA can be; health desired. a bit complex to run the equation to get calculate % below 100% or other % of strong for local areas. savings accounts can be at counts or percents below the people at COLA adjusted poverty level limited) adjusted level. or <200% of such langauge potential access barrier culture potential access barrier this factor can be bound with how services can or cannot be accessed -- strongly affects whether an area if there are very small populations, distance potential access barrier may be considered "medically and it becomes difficult for underserved" communities or even large areas to support services. this factor can be bound with how services can or cannot be accessed -- strongly affects whether an area if there are very small populations, insular/island potential access barrier may be considered "medically and it becomes difficult for underserved" communities or even large areas to support services. this factor can be bound with how services can or cannot be accessed -- strongly affects whether an area sparse population if there are very small populations, potential access barrier may be considered "medically (frontier) and it becomes difficult for underserved" communities or even large areas to support services.
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