Panel Presentation

Shortage Area Designations

Larry Allen, Center for Rural HealthElizabeth Cobb, KY Hospital Association

Steve Salt, KY Department for Public Health

ORIGIN OF SHORTAGE DESIGNATIONS

Health Professional Shortage Area

• National Health Service Corps (NHSC) was created in 1971

• NHSC need determination process was expanded in 1978 to include poverty, infant mortality rate or birthrate and access barrier measures

• This expanded methodology is the current HPSA designation methodology

• Required to be reviewed every three years

ORIGIN OF SHORTAGE DESIGNATIONS

Medically Underserved Areas or Populations (MUA/P)

• MUA/P process was developed in 1975 to create grant opportunities for Community Health Centers (CHCs)

• MUA/P process uses similar measures as the HPSA but also includes % 65 years and older

• MUA/Ps have no review requirement – DESIGNATION FOR LIFE!

DESIGNATION REQUIREMENTS FOR CERTAIN FEDERAL PROGRAMS

Shortage Designation Option

National Health Service Corps

Federally Qualified

Health Center

Program

CMS Medicare Incentive Payment

CMS Rural Health Clinic

Program

J-1 Visa Waiver

Primary Care HPSA X   X X X

Dental Care HPSA X        

Mental Health HPSA X       X

Geographic HPSA X   X X X

Population HPSA X     X X

Facility HPSA X       X

Exceptional MUP   X     X

Medically Underserved Area

  X     X

Medically Underserved Population

  X     X

State Governor’s Certified Shortage Area

      X  

HPSA DESIGNATION PROCESS

Calculate the population to provider ratio• Must meet threshold of 3500:1

Consider contiguous areas• Identify on the map the boundaries and population

center of the proposed service area• Evaluate each area to determine the availability of

resources If area meets ratio requirement AND you can

rule out service availability in all contiguous areas, a recommendation is made to HRSA for designation

Recent Policy Changes

HRSA Policy

Recent Changes

• HRSA Proposed Changes in 1998 and 2008 – Never made final

• ACA 0f 2010 requires changes to the shortage area designation methodology• Negotiated Rule Making Process (June 2011)

• If no consensus, Secretary to publish an Interim Final Rule for new methodology (June 2012)

“Negotiated Rulemaking” What is it?

• Statutory basis: Negotiated Rulemaking Act of 1996 encouraged the use of negotiation to determine complicated regulations and directed agencies and negotiated rulemaking committees to “use consensus to the maximum extent possible consistent with law.”

8

“Negotiated Rulemaking” Who was involved?

• Secretary Kathleen Sebelius made appointments summer 2010

• Criteria for selection : 28 experts representing • Community Health Centers, rural health clinics and health care

practitioners,

• Representatives of special populations with unique health care needs,

• Technical experts in the area of research in health care access and statistical methods

• State Offices of Rural Health and Primary Care

• Role of DHHS/HRSA: One representative on the NRMC – Ed Salsberg, support staff in regular attendance

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Timeline and Progress of the Negotiated Rulemaking

• Secretary Sebelius appointed members July 2010

• First meeting – September 2010 Completion by July 1 and then… Extension granted Final meeting – October 2011 (14 month

process) Final Report to Secretary October 31, 2011

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Sub-committees and Work Groups

Tackling the content areas:–Measuring “underservice”

• Population and providers for “P2P” – Population to Provider Ratios

–Counting providers, deciding on “back outs”–Population counts and age/sex adjustments, other

issues• Health Status• Barriers• Ability to Pay

–Updating “rational service area” definition–Considering Data Sources and Validity

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Notable Concern: “Yo-Yo Effect”

Need to exclude federally supported providers from the provider to population count:• NHSC

• SLRP

• FQHC

• RCH

Next Steps

• Report submitted to the Secretary 10/31/2011• “Interim Final Rule” to be posted….• Comments – will be accepted -- but HRSA does

not have to change the Interim Final Rule• Those organizations and entities represented by

Committee members will not comment adversely on sections on which there was consensus, but may comment on areas on which there was not consensus

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Concerns and Advocacy Efforts

Concerned future changes will be similar to previous proposal by HRSA which would have adversely impacted Kentucky

Need a more pro-active effort to influence the process

Need to educate lawmakers and others on the impact to Kentucky

PCO Designation Role

• Designated by HRSA to evaluate at state level

• HPSAs required to be reviewed every 3 years

• Methodology and data sources required by HRSA

• Activities to ensure accuracy

• Work with stakeholders to exhaust all efforts

Policy On Publication in FR

Proposed for withdrawal, not published in Federal Register

Some availability of designation benefits November 2011, began publishing

regularly

Published Withdrawal in Nov. 3, 2011 Federal Register

Anderson Barren Breathitt Clark Cumberland Daviess Fayette Fleming Greenup Johnson

Laurel Lawrence Marion Perry Shelby Trimble Warren Webster Whitley Hickman

(1) On (or about) Sept., 25, the PCO will send an e-mail recommending a County HPSA be withdrawn because the Population to Provider Criteria was not met.

(2) In mid-October HRSA will prepare the list of P’s (Proposed for Withdrawals) and N’s (No information forthcoming from the PCO =Proposed for Withdrawal). This list will be shared with the PCO’s to double check the information is correct.

(3) In November, HRSA will check the list of HPSAs Proposed for Withdrawal against the list of NHSC individual and site applications. (HRSA will not impact pending NHSC matches-vacancies by a change in HPSA status).

(4) In November, the HPSAFIND (HRSA website) status will be changed to Proposed Withdrawal.

HPSAs to be Updated`

PCO Due Date OSD 90 Day Review

HPSA Find Update FR Notice FR Publish

2008 Sept. 30, 2012 Oct. 30, 2012 November June 1, 2013 July 1, 2013

HPSA Federal Register Notice Update ScheduleHPSAs to be Updated

PCO Due Date OSD 90 Day Review HPSA Find Update FR Notice FR Publish

2008 Sept. 30, 2012 Oct. 30, 2012 November June 1, 2013 July 1, 2013

2009 March 30, 2013 June 30, 2013 July June 1, 2014 July 1, 2014

2010 December 31, 2013 March 30, 2014 June 1, 2014 June 1, 2014 July 1, 2014

Data Sources

American Community Survey – • large national survey

• uses continuous measurement methods to produce detailed population estimates each year

• Current survey information from period 2006-2010

2011-2012 HPSA Activity

Adair 2012-5 Bath 2012-12 Nicholas -Withdrawn

Bracken ???? Breckinridge 2012-15 Ohio 2012-9

Caldwell – PW Carter 2011-6 Robertson 2011-14

Clay 2011-13 Crittenden 2012-11 Russell 2012-5

Elliott 2011-9 Estill – PW Todd 2012-13

Green – PW Harlan (partial) 2012-16 Washington 2011-11

Hart – PW Jackson 2012-14 Wayne 2012-11

Jefferson 2011-8 Knox 2012-11 Wolfe - PW

Larue 2011-11 Leslie 2012-14

Lewis 2012-8 Livingston – Withdrawn

Logan 2012-11 Lyon 2012-6

Madison – PW Magoffin 2011-11

Marion 2011-10 McLean 2012-10

Meade ???? Menifee 2011-13

Metcalfe 2012-16 Muhlenberg - PW

Recent Trends

Overview of gains and losses for 2011-2012

Sample designation profiles

HPSA Determination: Hart

Items Criteria Value Result

Valid Rational Service Area Yes No Does Not Pass

Designation Population < 250000 17684 Pass

Pop/FTE Ratio >= 3500:1 5053:1 Pass

200% of Poverty None 50.21% Pass

Overall Contig Area Availability No Yes Does Not Pass

HPSA Determination Does Not Qualify

HPSA Determination – Hart 2

Type Criteria Value Scoring Table Value Weighted Value

Population/Provider Ratio 5053:1 4 8

Poverty Percent 23.5 2 2

Low Birthweight Rate 7 11

Infant Mortality Rate Per 1000 Births 6 0

Travel Time (Minutes) 0 00

Travel Distance (Miles) 0 0

HPSA Greatest Need Scoring 11

HPSA Degree of Shortage 2

Physician Short 1.553

UnderServed 10684

HPSA Determination – Hart 3

Contiguous Areas

CACA Name

HPSA Name

HPSA Category

Available CA

In-accessible

Over Utilized

Excessively Distant

Sig Socio-Economic Diff

Other Access Barriers

Pop/Provider Ratio

100% Pov

200% Pov

Travel Mile

Travel Time (Mins)

Travel Mode

1210011379

S - Barren County

NONE

Yes No No No No No 1381:1

18.73 42.65 4.4 6.6Private

HPSA Determination: Wolfe County

Type Criteria Value Scoring Table ValueWeighted Value

Population/Provider Ratio 2399:1 0 0

Poverty Percent 42.2 4 4

Low Birthweight Rate 10 3

3Infant Mortality Rate Per 1000 Births

11 1

Travel Time (Minutes) 0 00

Travel Distance (Miles) 0 0

HPSA Greatest Need Scoring 7

HPSA Degree of Shortage

Physician Short -0.601

UnderServed 1196

Panel Questions?