1. Goal: Select the most promising model for geographic HPSA designation to fully test July 20, 2011 1

2. The opportunity to direct this process is now. The time for big decisions has come. 2

3. 3

4. July 2011 NRMC Meeting GEO HPSA 4

5. Other Ways to Designate GEO HPSA 5

6. A modest proposal for decision making the burden on the applicant should be reasonable and as simple as possible there should be an evidence basis for decisions the committee makes GEO HPSA 6

7. A modest proposal for decision making the method should have acceptable performance in that it meaningfully identifies and orders the areas of need the consequences to existing safety-net providers and the communities they serve should be considered in the outcome GEO HPSA REASONABLE EVIDENCE BASED

8. Important Considerations The results are for geographic HPSAs only Based on PCSAs Provider data over-counts FTE Consequences for Medicare Bonus cannot be ignored Total designated population cannot be ignored Results are based on test thresholds only GEO HPSA REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES 8

9. Geographic HPSA Models * Model A1: Tiered P2P, Continuous Threshold Model A2: Tiered P2P, Threshold Trigger Model A3: Tiered P2P, Factor Analysis Model B1: Index with Barrier Measure Choice Model B2: Index with Defined Barrier Measures Model B3: Index with Expert Judgment WeightingExpert Opinion Statistical Weighting Expert Opinion Expert, Alt. on Barriers Expert, Alt. on Barriers July 8, 2011 Unit of analysis: Counties, Primary Care Service Areas and Selected State RSAs. GEO HPSA REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES MEDICARE BONUS TOTAL POP DESIG TEST THRESHOLDS 9

10. GEO HPSA Sequential/TieredIndex MenuSet List Expert Opinion Factor Analysis Cutoff Threshold Continuous GEO HPSA REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES MEDICARE BONUS TOTAL POP DESIG TEST THRESHOLDS 10

11. GEO HPSA Sequential/Tiered Expert Opinion Factor Analysis Cutoff Threshold Continuous A2: Triggered Threshold A1: Continuous Threshold A3: Statistical Weighting GEO HPSA REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES MEDICARE BONUS TOTAL POP DESIG TEST THRESHOLDS TIERED 11

12. HPSA A1, A2, A3 Initial Thresholds run – 2500:1 (worst 10% pop) Fewer providers then YES – 1300:1 (median pop) More providers then NO Models differ only in how health status, access, ability to pay are treated for areas with P2P between 1300:1 and 2500:1 GEO HPSA REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES MEDICARE BONUS TOTAL POP DESIG TEST THRESHOLDS TIERED 12

13. HPSA A1 (and A3) P2P Threshold – 2500:1 (worst 10%). Fewer providers then YES – 1300:1 (median). More providers then NO Between 1300:1 & 2500:1, consider health status, access, ability to pay As health status/access/ATP gets worse, you can be designated with more providers A1 and A3 differ in weighting of health status/access/ATP GEO HPSA REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES MEDICARE BONUS TOTAL POP DESIG TEST THRESHOLDS TIERED 13

14. HPSA A2 P2P Threshold – 2500:1 (worst 10%). Fewer providers then YES – 1300:1 (median). More providers then NO Between 1300:1 to 2500:1 P2P, there is a single threshold for adverse health status, access, ability to pay, regardless of actual P2P Tested worse 25% of pop GEO HPSA REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES MEDICARE BONUS TOTAL POP DESIG TEST THRESHOLDS TIERED 14

15. HPSA A1, A2, A3 Choices – Vary the P2P thresholds (1300:1, 2500:1) – How to consider health status, access and ability to pay Weighting Threshold GEO HPSA REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES MEDICARE BONUS TOTAL POP DESIG TEST THRESHOLDS TIERED 15

16. Geographic HPSA Models * Model A1: Tiered P2P, Continuous Threshold Model A2: Tiered P2P, Threshold Trigger Model A3: Tiered P2P, Factor Analysis Model B1: Index with Barrier Measure Choice Model B2: Index with Defined Barrier Measures Model B3: Index with Expert Judgment WeightingExpert Opinion Statistical Weighting Expert Opinion Expert, Alt. on Barriers Expert, Alt. on Barriers July 8, 2011 Unit of analysis: Counties, Primary Care Service Areas and Selected State RSAs. GEO HPSA REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES MEDICARE BONUS TOTAL POP DESIG TEST THRESHOLDS 16

17. GEO HPSA Sequential/TieredIndex MenuSet List Expert Opinion Factor Analysis Cutoff Threshold Continuous GEO HPSA REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES MEDICARE BONUS TOTAL POP DESIG TEST THRESHOLDS 17

18. GEO HPSA Index MenuSet List B1: Barrier Menu Choice B2: Defined Barrier Measures B3: Expert Judgment GEO HPSA REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES MEDICARE BONUS TOTAL POP DESIG TEST THRESHOLDS INDEX 18

19. HPSA B1, B2 Index model – all variables are considered in combination with others There is no Pop to Provider ratio that guarantees, nor precludes designation – Areas with many providers but bad health could be designated – Areas with few providers but good health may not be designated All inputs are combined into a single score for an RSA for designation GEO HPSA REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES MEDICARE BONUS TOTAL POP DESIG TEST THRESHOLDS INDEX 19

20. HPSA B1 Creating an index 90% weight to P2P; 10% to other 3 variables Combine all other non P2P variables using expert judgment weights Barriers menu: choose 2 variables from list of 6 Tested designation cutoff worst quartile (of areas) GEO HPSA REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES MEDICARE BONUS TOTAL POP DESIG TEST THRESHOLDS INDEX 20

21. HPSA B2 Creating an index 90% weight to P2P; 10% to other 3 variables Combine all other non P2P variables using expert judgment weights Barriers menu: choose 1 from risk variables and 1 from direct measures Tested designation cutoff worst quartile (of areas) GEO HPSA REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES MEDICARE BONUS TOTAL POP DESIG TEST THRESHOLDS INDEX 21

22. HPSA B3 This model differs from B2 only in the weight assigned to Pop to Provider v. other variables B3  50%/50% B2  90%/10% Tested designation cutoff worst quartile (of areas) GEO HPSA REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES MEDICARE BONUS TOTAL POP DESIG TEST THRESHOLDS INDEX 22

23. HPSA B1, B2, B3 How to combine variables Percentage of method assigned to Pop to Provider ratio v. other three aspects GEO HPSA REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES MEDICARE BONUS TOTAL POP DESIG TEST THRESHOLDS INDEX 23

24. How to use these results * To inform our thinking about the models Pick best model based on our judgment of the best way to determine underserved areas Models have flexibility and can be tweaked Use results to guide us to make the big decisions GEO HPSA REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES MEDICARE BONUS TOTAL POP DESIG TEST THRESHOLDS 24

25. Geo HPSA-Key Decisions * Pop: provider P2P – Threshold (absolute) – Tiered – Continuous Non P2P factors – How important non P2P (%) Providers – Included – Weight – Back outs GEO HPSA REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES MEDICARE BONUS TOTAL POP DESIG TEST THRESHOLDS 25

26. GEO HPSA Sequential/TieredIndex MenuSet List Expert Opinion Factor Analysis Cutoff Threshold Continuous What are the P2P thresholds? What are the relative weights? GEO HPSA GEO HPSA GEO HPSA REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES MEDICARE BONUS TOTAL POP DESIG TEST THRESHOLDS 26

27. Next Steps Brief large group discussion and questions Split group discussion Return to large group to present impact testing GEO HPSA REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES MEDICARE BONUS TOTAL POP DESIG TEST THRESHOLDS 27

28. Next Steps Brief large group discussion and questions Split group discussion Return to large group to report out Make a recommendation GEO HPSA REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES MEDICARE BONUS TOTAL POP DESIG TEST THRESHOLDS 28

29. Goal Reminder Select the most promising model for geographic HPSA designation to fully test GEO HPSA REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES MEDICARE BONUS TOTAL POP DESIG TEST THRESHOLDS 29