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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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posted:10/14/2011
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