2011 Virginia Rural Health Summit presentation

1. HPSA & MUA Negotiated Rulemaking April 7th, 2011 Alan Morgan Chief Executive OfficerNational Rural Health Association

2. More than 130 Hours: Three decisions

4. NRHA Mission The National Rural Health Association is a national membership organization with more than 22,000 members whose mission is to provide leadership on rural issues through advocacy, communications, education and research.

5. Who Are We? The voice for rural health care. A non-partisan, non-profit membership driven organization with over 20,000 members. A source of information for policymakers and NRHA members. A trusted resource for rural stakeholders.

7. Rural is Different More elderly and more disabled elderly More occupation related disability More injuries and injury related death (40% higher than in urban areas)

8. Rural Health Disparities 20 to 25% of nation’s population is rural More likely to report fair to poor health Rural counties 19.5% Urban counties 15.6% More obesity Rural counties 27.4% VS urban counties 23.9% Less likely to engage in moderate to vigorous exercise: rural 44% VS urban 45.4% More chronic disease (heart, diabetes, cancer) Diabetes in rural adults 9.6% VS urban adults 8.4%

9. Commonalities of Definitions of Rural Rural is often defined by what it is not…urban Rural is defined by: Geography Population density (urban areas or urban clusters 1,000 per square mile is urban; 6 per square mile is frontier Distance from an urban center (Rural Urban Commuting Area (RUCA codes) Culture Policy definitions (disparities, shortage areas, etc.)

10. Purpose of Shortage And Underserved Designationsof Definitions of Rural Identify areas of greatest need: limited resources prioritized and directed to people in those areas. If an area meets the criteria for designation, programs targeted at enhancing the primary care infrastructure through recruitment and retention of providers and primary health care facilities become available to the area.

11. Health Professional Shortage Area(HPSA) DesignationDefinitions of Rural Developed as mechanism for prioritizing National Health Service Corps (NHSC) placements in the 1970s. Current criteria have been essentially unchanged since the 1980s. Designation based on an elevated ratio of the population to the number of primary care physicians in a rational service area.

12. 6,204 Primary Care HPSAs with 65 million people living in them. It would take 16,643 practitioners to meet their need for primary care providers (a population to practitioner ratio of 2,000:1. 4,230 Dental HPSAs with 49 million people living in them. It would take 9,642 practitioners to meet their need for dental providers (a population to practitioner ratio of 3,000:1). 3,291 Mental Health HPSAs with 80 million people living in them. It would take 5,338 practitioners to meet their need for mental health providers (a population to practitioner ratio of 10,000:1).

13. Medically Underserved Area/Population(MUA/P) DesignationDefinitions of Rural Developed to regulate the Federally Qualified Health Center (FQHC) program Current criteria have been essentially unchanged since the 1980s Designation based on scores for 4 equally weighted high need indicators: Percent of population in poverty, percent of population over age 65, infant mortality rate, ratio of primary care physicians to the population.

14. Programs Utilizing HPSA and MUA/PDesignations National Health Service Corps Scholarship Loan Repayment State Loan Repayment Program Section 330 Health Center Grants FQHC Look-Alike Certification Medicare Incentive Payment Program

15. Programs Utilizing HPSA and MUA/PDesignations - Rural Health Clinics Eligible Area - Recruitment of Foreign Born Physicians J-1 Visa Waiver National Interest Waiver - Scoring Preference for Title VII & VIII Grants

16. What’s Wrong With CurrentDesignations? 1.) Having two similar designations for different programs can be confusing and creates a burden on local communities applying for designation 2.) Counting only physicians gives an incomplete picture of the availability of primary care resources 3.) Current high-need indicators are not sufficient to capture real access issues 4.) There is no update requirement for MUA/P designations – some are over 20 years old 5.) The current method facilitates a “yo-yo” effect of designation gain and loss 6.) Current methods may not reflect true need

17. If At First You Don’t Succeed… 1.) A new method was proposed in 1998 but rejected due to overwhelming negative comment. Viewed as extremely disruptive to existing designations and safety-net providers, especially in rural areas. 2.) Again, HRSA attempted to proposed a new methodology in 2008, but rejected due to overwhelming negative comment. Viewed as extremely disruptive to existing designations and safety-net providers, especially in rural areas.

18. Try, try again… Created by the ACA to review criteria for the designation of Medically Underserved Areas and Health Professional Shortage Areas. The Committee comprises 28 members who are key stakeholders representing the programs most affected the designations, including health centers, rural health clinics and other rural providers, special populations with unique health care needs, and technical experts in health care access and statistical methods.

19. Public Comment Contact: Nicole PattersonOffice of Shortage Designation, Bureau of Health ProfessionsHealth Resources and Services AdministrationRoom 9A–18Parklawn Building5600 Fishers LaneRockville, Maryland 20857301-443–9027 301-443–9027npatterson@hrsa.gov

20. The Bottom Line Thou shall have two definitions. Federal physicians should be backed out for the purposes of determining shortage areas. “Primary Care” should include NPs and PAs.

21. Counting Clinicians “Primary Care” should include NPs and PAs?? Threshold of population to primary care provider ratio for designation: Including non physician primary care providers into the supply of workforce available will mean the ratios used for designation will be very different from the old 3500:1 or 3:000:1 for primary care physicians only that has been used since the mid-1970s.

22. Rational Service Areas For both geographic MUA and HPSA designations you have to pick a rational service area for medical services to then seek a designation. - It is far easier to identify the problems with any approach than it is to come up with something better.

23. Workgroup Approach “Barriers workgroup” considering the 3 non-provider parts of the index of medical underservice (health status, accessibility, ability to pay) is focused most on how to represent ability to pay and on the various measures of access.

24. Rational Service Areas Preliminary testing of DRAFT recommendations with both census tract, ZIP based and county based RSAs. Movement among the group away from the idea that we must pick a basic geographical building block approach to define rational service areas, and to allow areas to use different regimes.

25. Facility Designation? HPSA Facility designation subcategory of a 'magnet' or 'center of excellence?'

26. Weighting Issues As an example ONLY: MUA: health status 40%, access 20%, ability to pay 20% and provider 20%. HPSA: health status 30%, access 20%, ability to pay 10% and provider 40%.

27. Our Congressionally mandated target date for a draft final proposal is July 2011.

28. To date, no “weighting” decisions have been made. No impact testing has been done.

29. The Committee is seeking an extension in the timeline for completion of their tasks.

31. Join NRHA Today! www.ruralhealthweb.org Click button: Become a Member Access to Social Networking: NRHA Connect Regulatory and Legislative Guides E-news and Rural Roads Much, Much More