1. 1 NPRM2 OVERVIEW Review of Proposed Methodology for Historical Context

2. 2 NPRM-2 Stated Goals Methodological Goals: –Simplicity –Face Validity –Science Based –Minimize Unnecessary Disruption –Acceptable Performance Process Goals –Consolidation & Simplification –Proactivity –Automation –Increased State Role –Reduce the Need for Population Group Designations

3. 3 Some Framing Decisions There would be a single methodology and designation process for primary care HPSAs and MUAs Metric used would be expressed as a ratio of population to provider. Allow for national designations as well as individual State/local applications for designation There would be two “tiers” of designation  Tier 1: meets criteria when both federal and non- federal resources included Considered eligible for additional federal resources  Tier 2: meets criteria only if existing federal resources are excluded; Able to maintain existing level of federal resources

4. 4 Steps in the Conceptual Framework 1.Calculate numerator for the Population: Provider ratio –Effective ‘Barrier Free’ population 2.Calculate denominator for the Population: Provider ratio –Supply of primary care providers 3.Calculate ‘base’ population:provider ratio 4.Adjust for increased need based on community characteristics 5.Compare the final adjusted effective barrier-free population:provider ratio against a threshold of underservice 6.Determine Tiers of Shortage (Tier 1 vs Tier 2) (7.) Designation of ‘Safety-Net Facilities’ as Primary Care HPSAs (and creation of related new MUP category)

5. 5 11/25/2015 Step 1. Calculate Adjusted Population Obtain local population counts by age & gender Multiply age/gender population counts by age/gender specific “Barrier-Free” utilization rates to get a barrier free visit count Office base visits (not primary care specific) for non-minority, non-poor, employed individuals Calculate the adjusted population by dividing resulting visits by the National mean visit rate for the Barrier Free population 11/25/2015

6. 6 Step 2. Calculate Provider Supply Count primary care physicians: –FP, GP, Gen.IM, Peds, Ob/Gyn) –Count residents in training as 0.1 FTE physician Count NPs, PAs and CNMs –Generally counted as 0.5 FTE physician –Local adjustment of FTEs permitted Max of 0.8 times a State-specific practice scope factor running from 0.5 to 1.0 (Wing et al., 2003). Combine resulting counts to get area provider supply

7. 7 Steps 3 & 4. Base and Adjusted Pop:Provider Ratio Step 3. Calculate Base Ratio of Population to Providers –Divide “Adjusted Population” calculated in Step 1 by Provider Supply calculated in Step 2 to get base ratio Step 4. Adjust Ratio for Increased Community Needs –Determine local service-area rate for 9 factors felt to be indicative of increased need for services –Poverty (<200%), Unemployment, Elderly, Population Density, Hispanic, Non-White, Death Rate, LBW, IMR –Determine percentile and weight for each community characteristic from look-up tables Factors derived from regression model of relative influence of selected factors on the Barrier-Free population:provider ratio in sample counties –Combine resulting weights for the 9 factors and add to the numerator the base Pop:Provider ratio

8. 8 Relative Weights of Community Characteristics

9. 9 Step 5. Compare to Threshold for Underservice Compare the adjusted Population:Provider ratio to a threshold of 3000:1 –An area with a ratio >= 3000:1 will be designated Benchmark score of 3000:1 justified as: –Two times “adequacy” ratio of 1500:1; supported by literature review and other data –Demarcating the lowest quartile of all scores –It is also consistent with current ratio used to identify high need areas and population groups

10. 10 Step 6. Two Tiered Approach to Shortage Concern about the “Yo-Yo” effect –If federal resources are counted, many areas where they exist would no longer be eligible and would lose them Concern about overestimates of need –If federal resources are not counted, are we overestimating need? Solution -Allow “back-out” of existing federal resources to confirm need in absence of these resources -NHSC affiliated providers -Clinicians obligated under the State Loan Repayment Program Physicians with J–1 visa return-home waivers -Clinicians providing services at health centers funded under Section 330 Application: -Tier 1: Ratio w/o Federal-linked providers still >= 3000:1 -Tier 2: Ratio = 3000:1 w/o Fed. Providers

11. 11 EXAMPLE OF THE METHOD ANYTOWN, USA Start: POPULATION=30,215; PRACTITIONERS=11.4 Non-Fed; 5.1 Fed-linked = 17.0 CURRENT UNADJUSTED RATIO = 1777:1 Calculation: VISITS USING AGE/GENDER NON-BARRIERED RATES= 119,319 AVERAGE NON-BARRIERED RATE= 3.741 ADJUSTED POPULATION: 119,319/ 3.741 = 31,895 ADJUSTED POPULATION:PRACTITIONER RATIO: 31,895/17.0 = 1876:1 ADJUSTMENT FOR HIGH NEED INDICATORS (9 measures): +1119:1 “NEED FACTORS” ADDED TO THE NUMERATOR TO PRODUCE AN ADJUSTED TIER 1 POPULATION:PROVIDER RATIO = 2995:1 DOES NOT PASS (31895/17.0)= 1876 + 1119 = 2995:1 RE-CALCULATE RATIO WITHOUT FEDERALLY LINKED PROVIDERS TIER 2 POPULATION:PROVIDER RATIO = 3917:1 PASSES (31,895/11.4)= 2798 + 1119 = 3917:1

12. 12 Safety Net Facility Option For facilities located in areas that did not meet the new geographic or population group criteria –Must be part of an FQHC, RHC or other public or non- profit private medical facility –Provides full time primary medical care services on an ambulatory or outpatient basis –Sees patients regardless of ability to pay, posted SFS –Meets percentage threshold of safety-net service: Indigent/uninsured served on SFS discount policy = 10% OR SFS + Medicaid = –40% in metropolitan areas –30% in non-metropolitan, non-frontier areas –20% in frontier,non-metropolitan areas Would result in designation as: Facility HPSA Medically Underserved Population –New category based on population served at Safety-net facility

13. 13 IMPLEMENTATION PLAN 3-year phase in – oldest designations first Areas that were qualified based on an initial calculations done using national data for existing service areas would be designated directly (HPSA and MUA areas, counties, PCSAs, State RSAs, etc.) RSA provisions similar to current HPSA State RSA plans exempt from contiguous area analysis Areas that did not qualify would have the option to re- define area, to submit alternative data, or pursue population designations Technical assistance available to communities to assess impact of proposed methodology