A New Methodology for Identifying Primary Care Rational Service Areas

Long Island

Robert Martiniano, Project Director, CHWSDavid Armstrong, Ph.D., CHWSBeverly Grossman, CHCANYS

Center for Health Workforce StudiesSchool of Public Health, SUNY at Albany

(518) 402-0250http://chws.albany.edurpm06@health.state.ny.us

March 11, 2011

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Today’s Presentation

Background on Shortage Area Guidelines

Trends in Physician Supply HEAL 9 Project

OverviewRational Service Area Methodology Long Island RSAsFeedback from Stakeholders

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Current HPSA Guidelines

Health Professional Shortage Areas (HPSA)•Primary care, dental health, and mental health•Geographic, special population, and facility •Designation criteria

• A defined rational service area• 3,500 to 1 population to provider ratio (3,000

to 1 for special populations or high need geographic)

• Services deemed inaccessible in contiguous areas

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Current MUA/P Guidelines

Medically Underserved Area or Population (MUA/P)•Primary care only•Geographic or special population•Designation criteria

• A defined rational service area• Weighted score of 62 or less based on

• Population to provider ratio• Percent of the population under 100% of the

Federal Poverty Level• Percent of the population 65 years of age or

older• Infant mortality rate

•Governor’s Exceptions

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What are Shortage Area Designations Used for?

HPSA Designations are used for:• National Health Service Corp placements• J-1 Visa Waiver placements• Doctors Across New York placements• 10% Medicare enhanced rate (primary care geographic)

Medically Underserved Area/Population are used for:• Federal 330 new sites or expansion funding• J-1 Visa Waiver placements• Doctors Across New York placements

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Proposed 2008 Guidelines

• Proposed 2008 Guidelines• Merged HPSA and MUA/P• Adjusted the population to account for

• Age• Mortality• Race/ethnicity• Poverty• Population density

• Eliminated contiguous area analysis if a state has a statewide set of rational service areas

• Included midwifes, nurse practitioners, and physician assistants in the primary care provider count

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HEAL 9 Health Planning Grant

Problem 1: The current approach used to identify and designate primary care shortage areas in New York is fragmented

Problem 2: New York is not prepared for potential changes in shortage area guidelines

Solution: In collaboration with CHCANYS, conduct a comprehensive statewide primary care assessment Rational Service Area (RSA) development Primary care provider data collection Primary care capacity assessment

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Trends in Physician Supply

The Supply and Distribution of Community-Based Primary Care Physicians in New York is Changing

Region

Supply

Per 100k

Change

Capital District

78 8.0%

Central NY 68 -0.4%

Finger Lakes 81 10.8%

Hudson Valley 84 -1.4%

Long Island 88 0.3%

Mohawk Valley

61 -1.9%

NYC 89 -1.5%

North Country 64 8.6%

Southern Tier 76 7.2%

Western NY 69 2.0%

Statewide 82 0.7%Source: New York Physician Re-Registration Survey, 2005-2009

March 2011

Change in Community-based Primary Care FTEs, 2005 - 2009

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The View from 10,000 Feet: We Know What We Don’t Know

The extent to which NPs, PAs, and midwives provide primary care services

How many community-based primary care physicians provide care to underserved populations

How far people travel (beyond county boundaries) for primary care services

Impact of expanded access to health insurance on demand for primary care

How the denominator is changing – a smaller, but older population upstate

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Current Shortage

Designations

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Primary Care HPSAs in New York

Nassau County Has One Current MUP

Designation

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• Nassau and Suffolk counties have no current primary care HPSA designations.

• Nassau has a MUP designation under Governor’s exception.

Hold for map

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There is One Current MUA and One Current MUP in Suffolk

•1 MUA serving a population of over 5,000

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METHODS

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Developing RSAs: Cluster Analysis

Used by the Economic Research Service of the U.S. Department of Agriculture to construct commuting zones based on 1980 and 1990 journey-to-work data

Adapted this methodology for primary care RSAs throughout the state by analyzing patient commuting patterns for primary care office visits

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Comparison to Primary Care Service Areas (PCSAs)

PCSAs are a potential alternative to creating RSAs

Created by Goodman et al. (Dartmouth) Used Medicare claims data to assign

each zip code to a PCSA based on where the largest proportion of patients go for primary care

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Data Sources for Developing RSAs

Medicare Medicaid Health plan association data from

11 major private insurers Data on the uninsured from

community health centers

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Methodology

The basic unit of data analysis was patient care commuting flows between zip codes.

From each data set: Patient residential zip code Primary care physician zip code

In some datasets patients had a designated PCP

In other datasets, primary care visits identified by CPT codes and physician specialty were used to determine a PCP

Zip codes were combined based on commuting patterns using a cluster analysis

Zip codes were then translated into townships (rural areas) and census tracts (urban areas)

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Statewide, 317 Preliminary Primary Care RSAs Were Created Using this Methodology

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More RSAs Would Qualify Under 2008 Proposed Rules than Current Rules for Geographic Designations

HPSA Rules # Qualified Population

Current Geographic 82 1,543,200

Current Special Population, Medicaid

155 N/A

Proposed 2008 Geographic

112 3,837,400

Current rules for geographic designations may not benefit New York State

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Long Island

RSAs

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RSAs in Nassau

There are 20 RSAs in Nassau County

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RSAs in Suffolk

There are 18 RSAs in Suffolk County

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Current Geographic HPSA Guidelines

Under current rules, 3 RSAs would qualify for primary care geographic HPSA designation serving a population of 45,000

0 geographic HPSAs currently in the region

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Current Geographic HPSA Guidelines

Under current rules, 3 RSAs would qualify for primary care geographic HPSA designation serving a population of 40,000

0 geographic HPSAs currently in the region

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2008 Proposed HPSA Guidelines

Under the 2008 proposed rules, 3 RSAs would qualify for primary care geographic HPSA designation

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Under the 2008 proposed rules, 3 RSAs would qualify for primary care geographic HPSA designation

2008 Proposed HPSA Guidelines

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Current Special Population Guidelines

2 RSAs would qualify for special population, Medicaid-eligible designation

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1 RSA would qualify for special population, Medicaid-eligible designation

Current Special Population Guidelines

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MUA Designations Under Current Rules

No RSAs in either Nassau or Suffolk counties would qualify for MUAs.

There is current one Governor’s Exception designation in Nassau County.

There are two MUA/P designations in Suffolk County.

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Next Steps in the Project

Continue with local meetings Develop and compare RSAs using the

different insurance types, i.e., Medicaid, Medicare, commercial, and uninsured

Finalize methodology and/or RSAs

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Looking Ahead: Using RSAs Create a more systematic and streamlined

approach to the identification and designation of HPSAs and MUA/Ps

Inform impact analyses for proposed changes to update HPSA and MUA/P methodologiesHealth reform statute requires ‘negotiated rule

making’ for revisions to current methodologies Support local health planning efforts Inform state policies and programs

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Assessing the RSAs

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Questions to Consider When Assessing the Proposed RSAs

• Do these RSAs seem reasonable based on your knowledge of the region?

• Are there unique circumstances within your region that could affect travel patterns to primary care services, including:

• Changes in the service delivery system (expansions or reductions) since 2007?

• Physical barriers (highway construction, bridge closures, etc.)?

• Changes in the availability of public transportation since 2007?

• Special populations that may not have been considered in the assessment of commuting patterns?

• Any other issues that could affect the travel patterns of individuals to primary care services?

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RSAs in NassauAre there unique circumstances within your region that could affect travel patterns to primary care services, including:•Changes in the service delivery system (expansions or reductions) since 2007?• Physical barriers (highway construction, bridge closures, etc.)?• Changes in the availability of public transportation since 2007?• Special populations that may not have been considered in the assessment of commuting patterns?• Any other issues that could affect the travel patterns of individuals to primary care services?

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RSAs in Suffolk