Shortage Designation Modernization November 1, 2016

Melissa Ryan Acting Deputy Director, Division of Policy and Shortage Designation Bureau of Health Workforce (BHW) Health Resources and Services Administration (HRSA)

Today’s Discussion Topics

1. Refresher on Key Concepts for Shortage Designation

• Programs that Use Shortage Designations

• Types of Health Professional Shortage Area (HPSA) Designations

• HPSA Designation Criteria

• HPSA Scoring Criteria and Calculations

2. Shortage Designation Modernization Project

3. What does this mean for Primary Care Associations and Community Health Centers?

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1. Refresher on Key Concepts for Shortage Designation

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Shortage Designations Not just the NHSC and CHC Program Anymore

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Shortage Designation Option National

Health Service

Corps (NHSC)

NURSE

Corps

Health Center

Program

CMS Medicare

Incentive

Payment

CMS Rural

Health Clinic

Program

J-1 Visa

Waiver

Primary Care

Geographic HPSA X X X X X

Population HPSA X X X X

Facility HPSA X X X

Dental Care

Geographic HPSA X

Population HPSA X

Facility HPSA X

Mental Health

Geographic HPSA X X X X

Population HPSA X X X

Facility HPSA X X X

Exceptional MUP X X

Medically Underserved Area X X X

Medically Underserved Population X X

State Governor's Certified Shortage Area X

Types of HPSAs

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Primary Care

Mental Health

Dental Health

Population Group

Facility

A shortage of:

providers in a:

Geographic Area

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Population Facility

While the general components of designation analysis are similar across designation types, the specific eligibility criteria vary depending on designation type…

Geographic Area

HPSA Designation Criteria

In order to achieve a designation, the area under consideration must:

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HPSA Designation Criteria

Be a rational area for the delivery of services;

Have a certain ratio of population to providers serving the area that has been determined to qualify as a shortage; and

Demonstrate that health professionals in contiguous areas are

excessively distant, over-utilized, or inaccessible to the population under consideration.

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2

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Rational Service Area

Rational Service Area (RSA)

A state-identified geographic area within which most area residents could or do seek and obtain most of their

health care services

RSAs can be: 1) A whole county 2) Multiple counties 3) Sub-counties 4) Statewide Rational Service Areas (SRSA) 5) Catchment areas (for mental health only)

Rules of RSA Determination: 1) RSAs cannot overlap existing designations 2) RSAs cannot be smaller than a census tract 3) Exceed travel time between population centers 4) RSAs cannot carve out interior portions

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1

Ratio of Population to Providers Which Providers Count?

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Primary Care Mental Health Dental Health

Includes Doctors of Medicine (MD) and Doctors of Osteopathy (DO) who provide services in the following specialties:

Family Practice Internal Medicine Obstetrics and Gynecology Pediatrics

Includes: Psychiatrists and sometimes Clinical Psychologists Clinical Social Workers Psychiatric Nurse Specialists Marriage & Family Therapists

Includes: Dentists Dental Auxiliaries

Dental auxiliaries are defined as any non-dentist staff employed by the dentist to assist in the operation of the practice.

Note: Providers solely engaged in administration, research or training are excluded.

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Ratio of Population to Providers What are the ratios?

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Each HPSA category has a unique ratio of population to providers,

which has been identified as the point at which it can be designated as having a shortage of health professionals.

*Excludes high-needs and special population designations, which have distinct ratios

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Primary Care Mental Health Dental Health

Geographic 3,500:1 6,000:1 & 20,000:1 CMH and Psychiatrists

OR 9,000:1 30,000:1

CMH only Psy only

5,000:1

Population 3,000:1 4,500:1 & 15,000:1 CMH and Psychiatrists

OR 6,000:1 20,000:1

CMH only Psy only

4,000:1

Facility 1,000:1 2,000:1 1,500:1

Min Pop 500 Min Inmate Pop 250 Min Pop 1,000

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• Population of the area must meet at least one of several criteria demonstrating higher than normal need.

At least 20% of the population at or below 100% FPL The youth ratio exceeds 0.6 The elderly ratio exceeds 0.25 A high prevalence of alcoholism A high degree of substance abuse

At least 20% population at or below 100% FPL More than 100 births/year per 1,000 women ages 15-44 More than 20 infant deaths per 1,000 live births Have insufficient capacity

At least 20% of the population has income at or below 100% FPL More than 50% of the population has no fluoridated water Have insufficient capacity

Ratio of Population to Providers What constitutes high need? 2

Review of Contiguous Area (CA) Resources

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3

Are the providers excessively distant?

Are the providers over-utilized?

Are the CA providers inaccessible?

Is there a demographic disparity?

Does the CA have economic barriers?

When determining whether an area’s “neighbors” are accessible for health care services, HRSA asks:

Facility HPSA Designations

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Federal and State Correctional Institutions

State and County Mental Hospitals

Public or Non-Profit Medical Facilities

Have an average daily inpatient census of at

least 100 The number of workload

units per psychiatrist

FTE exceeds 300

Be medium or maximum

security

Have at least 250 inmates

Meet internees/year to provider ratio thresholds:

Primary Care

Dental Health

Mental Health

1,000:1 1,500:1 2,000:1

Provide primary care, dental, or mental health services to a similarly

designated geographic

or population HPSA

Have insufficient capacity to meet the

needs of that area or population group

Automatically Designated HPSAs

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Using the statute and regulations, HRSA has deemed the following facility types as eligible for automatic HPSAs:

Health Centers (funded under Sec. 330) Health Center Look-Alikes Tribally-Run Clinics Urban Indian Organizations Dual-Funded Tribal Health Centers Federally-Run Indian Health Service Clinics Rural Health Clinics

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Other HPSAs Automatic Facility HPSAs

Auto HPSAs compared to other HPSAs: Similar but not the same

• Designation & scoring done online • Criteria used to first designate as

HPSA • Criteria used to determine HPSA score • Scores range from 0-25 (26 for dental) • Designations are required to be

reviewed and updated as necessary annually

• Score of “0” is rare

• Designation & scoring currently done manually

• No designation process necessary • Same criteria used to determine HPSA

score as other HPSAs • Same scoring range used • HRSA has not historically required Auto

HPSA scores to be reviewed regularly; updates are requested by facility

• Score of “0” more frequent and means low shortage or no data was available for scoring

HPSA scores are based on a variety of factors and range from 0 to 25 in the case of Primary Care and Mental Health, and 0 to 26 in the case of Dental Health.

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HPSA Scoring Criteria

Primary Care 0-25

Dental Health 0-26

Mental Health 0-25

HPSA Scoring Calculations

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Primary Care

Dental Health

Mental Health

Factor Max Pts Awarded

Multiplier Total

Points Possible

Max Pts Awarded

Multiplier Total

Points Possible

Max Pts Awarded

Population : Provider Ratio 5 x 2 = 10 5 x 2 = 10 7

% of Population below FPL 5 x 1 = 5 5 x 2 = 10 5

Travel distance/time to NSC

5 x 1 = 5 5 x 1 = 5 5

Ratio of children under 18 to adults 18-64

5 x 1 = 5 1 x 1 = 1 3

Ratio of adults 65 and older to adults 18-64

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Substance prevalence 1

Alcohol abuse prevalence 1

Max Score: = 25 = 26 = 25

How are HPSA Scores Used?

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1

2

1

Award Levels

Priority in Awards Funding Preference

3 Scholar Placement

2 Scholar Placement

2. Shortage Designation Modernization Project

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Shortage Designation Modernization Project

Bridging people, processes, and data

Shortage Designation

Project

Regular Updates

Designation Updates of Scores via Standard Data

Use of Predefined

Rational Service Areas

Standard Data Sets

Auditable & Traceable

Projections Based on Standard Data

Impact Analysis & Trending

Defined Roles & Responsibilities

New Business Process & Functions

Single, Automated

System for all Processing &

Scoring

Shortage Designation Management System (SDMS) …

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DATA

CDC

CMS

Census ACS

… is an application tool used to manage

designations

… uses standard data sets to calculate

designations

… is based on regulations

• Standardized data are sourced from: • The Centers for Medicare and Medicaid Services (CMS) for provider data

• The Centers for Disease Control and Prevention (CDC) for infant health data

• The Census Bureau for population data

• The Environment Systems Research Institute (ESRI) for travel and spatial mapping data

SDMS Data Sources

Federal Data Industry Data State Data

Population Data Population Data Health DataHealth Data

Infant Mortality Rate (IMR)

Low Birth Weight(LBW)

Total Resident Civilian Population

Ethnicity Populations: Hispanic, Caucasian,

Asian, etc.

Population at Federal Poverty Level

Providers Providers

Providers Address from National Provider Identifier

(NPI)

Youth & Elderly Population in Service

Area

Center for Medicare & Medicaid (CMS)

Centers for Disease Control and

Prevention(CDC)

Census Bureau(Census and ACS)

Travel DataTravel Data

Private Transportation Network

Environmental Systems Research

Institute (ESRI)

Data PointsData Points

Provider Attributes for HPSA FTE Calculation

Other Populations (Medicaid, Homeless, Migrant

Farmworker)

Fluoridation Rate

Alcohol & Substance Abuse Rate

State Primary Care Offices (PCOs)

Stakeholder Engagement

• State PCO/PCA/HRSA Steering Committee

• State PCO/HRSA Technical Working

Group • State PCO/HRSA Policy Working Group • PCO monthly conference calls

• Dedicated shortage designation email

box

• Individual State PCO interaction with HRSA Project Officers

• Individual State PCO technical assistance

• SDMS demos and hypercare sessions

• User guides, policy and procedures manuals

• Monthly National SDMS snapshots

• Monthly State-specific snapshots

• Webinars and trainings

Feedback Mechanisms for State Input:

Additional Support Resources:

Shortage Designation Project | Today & the Future

Today The Future Today * The Future

Every new or updated designation created uses the same standardized data. Application and review steps are fully automated and have eliminated manual processing. Business rules and system validations are reflective of regulation and policy and applied to every designation. Policy definition well aligned with authorizing statutes and regulations. Paper has been eliminated, excluding supporting documentation.

Every designation uses the same standardized data with the HPSA update and continue to source standardized data. Release additional functionality to streamline and automate. Continue requirements definition with State and HRSA involvement for additional functionality. Ongoing clarification of regulations in order to define policy and requirements. A fully automated, transparent shortage designation business process that leverages standardized, national data for timely and accurate designations.

*Currently, Auto-HPSAs scores are manually calculated outside of the Shortage Designation Management System and the information above does not apply. Until July 2017, scores will continue to be calculated based on non-standardized data and other individual site provided data.

3. What does this mean for Primary Care Associations and Community Health Centers?

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Auto-HPSA Manual Process Overview

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• Initial and re-scores are initiated by sites through email on an ad hoc basis

• Withdrawals are initiated on an ad hoc basis by SDB

• Scoring requests are processed in Excel by SDB analysts

• Scores are created using a myriad of non-standardized data sets and site-provided data and averaged at the network level

• Sub-scores and data points are not currently captured

• If the site’s score does not increase, the site may terminate its request and keep it’s existing score

Current, Manual Auto-HPSA Process

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Initial Score Request

Rescore Request

Auto-HPSAs: Automated Scoring Process (July 2017)

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Initial Score Request

Rescore Request

Auto-HPSAs: Manual vs. Automated Scoring Process

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Manual Automated

Process and data are consistent for all Auto-HPSAs*

Process and data are consistent with Geographic, Population and Facility HPSAs

Less prone to human error

Transparent

Efficient

Replicable

Auditable

*Provider data are dependent upon PCO validation.

PCAs and PCOs

• PCOs are actively validating provider data, upon which the impact analysis is dependent • Assist your PCO with data collection wherever possible

• PCOs will not have impact analysis results until January 2017

• Establish a regular dialogue with your PCO, if you have not done so already

• Help Health Centers understand the changes that will occur in July 2017

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A list of PCOs is available at: http://bhpr.hrsa.gov/shortage/hpsas/primarycareoffices.html

Shortage Designation Project Timeline

2014

•Initiated Shortage Designation Project

•Launched SDMS

•PCOs began validating provider data

2015

•PCOs began to submit new and updated Geographic, Population and Facility HPSA designations in SDMS

2016

•PCOs continue to submit new and updated Geographic, Population and Facility HPSA designations in SDMS

•PCOs continue to validate provider data

2017

•Provide impact analyses to stakeholders

•Incorporate Auto-HPSA scoring process into SDMS

•Update all* HPSA designations, including Auto-HPSAs, in SDMS

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*MUA/P Designations are not included in the July 2017 Designation Update.

Project Timeline—Upcoming Key Milestones*

October 2016

•PCOs finished validating** current providers

•HRSA begins impact analysis

January 2017

•Initial impact analysis, including Auto-HPSAs, provided to stakeholders

•Re-run impact analysis periodically

May 2017

•PCOs finish validating new providers

•Pull data for July 1 Federal Register Notice (FRN)

June 2017

•Second impact analysis, including Auto-HPSAs, provided to stakeholders

July 2017

•Publish FRN prior to Designation Update

•Update of all designations, including Auto-HPSAs

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.

*PCOs can submit, review, revise, or withdraw designations at any time. **Validate is defined as reviewing each eligible provider record to determine if the provider is providing service and, if not, omitting the provider; confirming that the NPPES/NPI address is correct and, if not, correcting the location (i.e., re-geocode or create a new location); adding practice locations, as necessary; and confirming that the defaults are correct or entering data for all the provider attributes for each eligible provider location.

Key Take-Aways

• The Shortage Designation Project is based on the principles of transparency, accountability, and parity.

• The current, manual process will continue to be used until July 2017.

• The scoring criteria are not changing. However, in July 2017:

• Standardized data sets will used to score Auto-HPSAs.

• Scores will be at the site level and no longer averaged across sites.

• All HPSA types, including Auto-HPSAs, will be updated based on standardized data and PCO-validated provider data.

• MUA/Ps will not be updated.

• At least two impact analyses will be provided to stakeholders to help sites, communities and states prepare for any changes that may occur.

• The first impact analysis will be available in January 2017.

• PCO-validated provider data are essential for meaningful impact analysis results.

• HRSA will consider program policies to mitigate and address concerns.

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Questions?

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Connect With Us

Melissa Ryan

Acting Deputy Director, Policy and Shortage Designation

Bureau of Health Workforce

Health Resources and Services Administration

Phone: 301-443-1648

Web: bhw.hrsa.gov

Workforce Connections newsletter: www.hrsa.gov/subscribe

LinkedIn: www.linkedin.com/company/national-health-service-corps

www.linkedin.com/company/nurse-corps

Twitter: twitter.com/HRSAgov

twitter.com/NHSCorps

Facebook: facebook.com/HHS.HRSA

facebook.com/nationalhealthservicecorps

facebook.com/HRSANURSECorps

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CHCANYS 2016 Statewide Conference & Clinical Forum

November 1, 2016

Robert Martiniano, DrPH, MPA

Senior Program Manager

Center for Health Workforce Studies

School of Public Health | University at Albany, SUNY

Robert.Martiniano@health.ny.gov

(518) 402-0250

New York State

Shortage Area Designations

The Center for Health Workforce Studies

at the University at Albany, SUNY

• Established in 1996

• Based at the University at Albany School of Public Health

• Committed to collecting and analyzing data to understand workforce

dynamics and trends

• Goal to inform public policies, the health and education sectors and

the public

• Broad array of funders in support of health workforce research

• Under contract with NYSDOH to develop shortage area applications

and provide technical assistance

2 http://chws.albany.edu

Past/Current Work

• Developed Medicaid-based Primary Care Service Areas

• Updated Provider Data

o Reviewed NPI data

– Addresses

– Medicaid data

– NHSC Placements/J-1 Visa Waivers

• Updating/creating shortage area applications

• Providing technical assistance on

o NHSC Site

o NHSC Placements

o Shortage area applications

• Representing NYS on National Impact Workgroup

Continued/Future Work

• Providing technical assistance on

o NHSC Site

o NHSC Placements

o Shortage area applications

• Reviewing re-scoring

• Working with NYSDOH to develop priority list

• Updating/creating shortage area applications

• Developing Dental RSAs based on Medicaid patient commuting patterns

Thank You

Questions?

Visit Us On:

http://chws.albany.edu 5

NHSC 101 CHCANYS16

November 1, 2016

AGENDA

1 LOAN REPAYMENT PROGRAM

2 SCHOLARSHIP PROGRAM

3 STUDENTS TO SERVICE

PROGRAM

4 STATE LOAN REPAYMENT

PROGRAM

5 NHSC IN NEW YORK

LOAN REPAYMENT

PROGRAM

LOAN REPAYMENT AWARD

The NHSC Loan Repayment Program offers priority funding to applicants who work at NHSC-approved sites in high-need areas, as defined by a Health Professional Shortage Area (HPSA) score.

INITIAL

AWARD

AMOUNTS

UP TO

$50,000 FOR 2 YEARS

Full-time

UP TO

$25,000 FOR 2 YEARS

Half-time

In FY15, awards were given to applicants working at sites with HPSA scores of 14 and above.

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ELIGIBILITY

U.S. citizen or

national

Currently work, or

applying to work, at

an NHSC-approved

site

Have unpaid

government or

commercial loans for

school tuition,

reasonable educational

expenses, and

reasonable living

expenses, segregated

from all other debts

Licensed to practice

in state where

employer site is

located

Must be licensed in one of the following eligible disciplines:

• Physician (MD or DO)

• Nurse practitioner (primary care)

• Certified nurse-midwife

• Physician assistant

• Dentist (general or pediatric)

• Dental hygienist

• Psychiatrist

• Psychologist (health service)

• Licensed clinical social worker

• Psychiatric nurse specialist

• Marriage and family therapist

• Licensed professional counselor

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SCHOLARSHIP

PROGRAM

STUDENTS PURSUING CAREERS IN PRIMARY CARE CAN RECEIVE

A SCHOLARSHIP NOW AND

SERVE LATER

THE SCHOLARSHIP* INCLUDES:

Payment of tuition and

required fees (tax-free)

Some other tax-free educational costs (books, etc.)

A monthly living stipend

(taxable)

*Available for up to 4 years 7

ELIGIBILITY

U.S. citizen or national

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Full-time student at an accredited school, pursuing a degree in:

• Medicine (DO or MD)

• Dentistry (DMD or DDS)

• Nurse practitioner

• Certified nurse-midwife

• Physician assistant (primary

care)

STUDENTS TO SERVICE

LOAN REPAYMENT PROGRAM

STUDENTS TO SERVICE AWARD

UP TO

$120,000 FOR 3 YEARS

Full-time Service

UP TO

$120,000 FOR 6 YEARS

Part-time Service

The NHSC offers up to $120,000 in tax-free loan repayment for 3 years of full-time

service or 6 years of half-time service. Loan repayment begins during residency.

With continued service, eligible providers may be able to pay off all their student loans.

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ELIGIBILITY

U.S. citizen or national Full-time student in the

final year at an

accredited school,

pursuing a degree

in Medicine (MD

or DO)

Planning to complete

an accredited primary

medical care residency

in an NHSC-approved

specialty (Internal

Medicine, Family

Practice, Pediatrics,

OB/GYN, Psychiatry

and Geriatrics)

Have unpaid

government or

commercial loans

for school tuition,

reasonable educational

expenses, and

reasonable living

expenses, segregated

from all other debts

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STATE LOAN REPAYMENT PROGRAM

37 STATES ARE GRANTEES

Provides cost-sharing grants to states to

operate their own loan repayment

programs for primary care providers in

underserved areas.

Eligible disciplines vary but may include

physicians, nurse practitioners, physician

assistants, dental professionals,

registered nurses, mental health

professionals, and pharmacists.

NHSC IN

NEW YORK

2016 NY NHSC Field Strength Report:

Where are NHSC clinicians serving?

SITE TYPE # of NY NHSC Clinicians

% of NY NHSC Field Strength

FQHCs 371 54.4%

Outpatient – Hospital Affiliated*** *153* *22.4%*

Community Outpatient – Non-Hospital 90 13.2%

Private Practice 39 5.7%

State/local Health Department 15 2.2%

Tribal/IHS Health Centers 7 1.0%

Correctional Facility/ICE 1 1.0%

TOTAL 682 100%

CONTACT INFORMATION

HRSA BWH Region 2 Team - We are here to help!

New York State Analysts

Steve Auerbach, MD, MPH, FAAP – SAuerbach@hrsa.gov

Toni Williams-Sims, MS – Twilliams-Sims@hrsa.gov

Apeksha Deshpande, MS, RD – ADeshpande@hrsa.gov

Wesley Tahsir-Rodgriguez, MPH - WTahsir-Rodriguez@hrsa.gov

Regional Supervisor

Anne Venner, MA – AVenner@hrsa.gov