Shortage Designation & Access Analysis Update

Wyoming Primary Care AssociationPower of Rural Conference

May 16, 2018

Agenda

• Designation Basics– Purpose / Process

– Current Status

• What’s New– Federal initiatives

– Wyoming and Local

• Insights and Findings

2

Glossary of Terms• ACS: American Community Survey• AI/AN: American Indian/Alaska Native• APCD: All-Payer Claims Database• CA: Contiguous Area• CDC: Centers for Disease Control• CHC: Community Health Center• CMHP: Core mental health providers

– PSY, CPSY, CSW, PNS, MFT, LPC : Psychiatrist, Clinical Psychologist, Clinical Social Worker, Psychiatric Nurse Practitioner, and Marriage and Family Therapist, Licensed Professional Counselor

• CMS: Centers for Medicare & Medicaid Services• CNM: Certified Nurse Midwife• CPT: Current Procedural Terminology• DC: Dental Care• E&M Codes: Evaluation and Management Codes• FPL: Federal Poverty Level• FTE: Full-time Equivalent• GDSC: Governor Designated/Secretary Certified• GIS: Geographic Information System• HCPCS: Healthcare Common Procedure Coding

System• HPSA: Health Professional Shortage Area• HRSA: Health Resources and Service

Administration• IHS: Indian Health Services•

• IMR: Infant Mortality Rate• J-1: Exchange Visitor Visa Program• LAL: Look-Alike Health Center• LBW: Low Birth Weight• MD, DO: Doctor of Medicine, Doctor of Osteopathic

Medicine• MH: Mental Health• MUA/P: Medically Underserved Area/Population• NSC: Nearest Source of Care NHSC: National Health

Service Corps• NP: Nurse Practitioner• NPI: National Provider Identifier• Ob/Gyn: Obstetrics/Gynecology• P2P: Population to Provider Ratio• PA: Physician Assistant• PC: Primary Care• PCO: Primary Care Office• PCSA: Primary Care Service Area• PPD: Population for whom Poverty Status is

Determined• RHC: Rural Health Clinic• RSA: Rational Service Area• SDMS: Shortage Designation Management System • SFS: Sliding Fee Scale• UDS: Uniform Data System

3

Designation History / Purpose• Established in the 1970’s to support 2 programs:

1. HPSAs = National Health Service Corps2. MUA/P = Community and Migrant Health Center program

– Many programs added since then• Regulatory Authority - To identify areas with sufficient need to

justify federal assistance

– Designation itself does not award resources • Eligibility to apply for related programs

– ‘Scoring’ used to identify “areas of greatest need”• Award of resources

– Not a full, modern, or comprehensive assessment of need

4

Types of Designation

• Health Professional Shortage Area (HPSA)– Geographic Area, Population Group, Facility

• Medically Underserved Area/Medically Underserved Population (MUA/P) – Geographic Area, Population Group

– Governor may also request an Exceptional MUP

• Governor Designated / Secretary Certified (GDSC) • WY Plan approved in 2008

• Pertains only to establishing Rural Health Clinics (RHCs) in areas that do not otherwise qualify

5

Federal Program Dependencies

6

Shortage Designation Option National Health Service

Corps (NHSC)

NURSE Corps Health Center

Program

CMS HPSA Bonus

Payment Program

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

Medically Underserved Area

(MUA)

X X X

Medically Underserved

Population (MUP)

X X

Exceptional MUP X X

State Governor's Certified

Shortage Area

X

Source: HRSA CRHCP: 998-50

HPSAs: Shortage of Providers• Three Disciplines:

– Primary Care

• Internal Medicine, Family Practice, Pediatrics, Ob/Gyn, Adolescent, Geriatric, General Practice

• Does not include non-physician PCPs (NP, PA, CNM)

– Dental

• General and Pediatric Dentists

• Dental hygienists and assistants factored in as a multiplier

– Mental Health

• Psychiatrist only

and/or

• Core Mental Health Providers – includes Psychiatrists, Clinical Psychologists, Clinical Social Workers, Psychiatric Nurse Specialists, Marriage and Family Therapists, Licensed Professional Counselors

7

Components of HPSA Designation

• Rational Service Area (RSA)

• Population to Provider Ratio (P2P)

• High Needs / Insufficient Capacity indicators

– Geographic only

• Contiguous Areas (CA)

• Nearest Source of Care (NSC)

– For scoring only

8

HPSA Categories• Geographic

– Total Population • Excludes institutionalized or ‘group quarters’ populations

• Population Groups – Low Income– Medicaid-Eligible– Homeless– Migrant Farmworker– Native American/Alaska Native

• Facilities• Federal and/or State correctional institutions• State/County mental hospitals• Public and/or non-profit mental health facilities• Automatic Facility Designation: Community Health Centers, Look-

Alikes, RHCs (with application), IHS/Tribal facilities

9

10

11

12

13

Rational Service Area (RSA)“Area population, that because of demographics, topography, market and/or transportation patterns or other factors, has limited access to health resources.”

– Single whole counties – Contiguous groups tracts, county subdivisions

• Service area must consider geography within 20 miles/30 minutes of population center (25 miles/40 min. for Mental & Dental)– By drive time or public transportation under certain conditions– Distance measured from population weighted centroid (NEW)– Can include smaller communities further out

• Service area may be further limited by: – Physical barriers– Socioeconomic differences– Established neighborhoods (> 20,000 pop)– Existing designations or over-utilization

• Narrative description of why the area is rational

14

Population to Provider Ratio (P2P)• Population: (Census / ACS)

– Resident civilian population aka. population for whom poverty status is determined (PPD)• Excludes individuals in group quarters and institutionalized

– Low income (<= 200% of the federal poverty level): • Must be >30% of the population in the service area

– Special Populations (sources vary)

• Providers:• Physicians/Dentists within each discipline

• Mental health has Psychiatrist or ‘Core Mental Health” option• Dental FTE adjusted by age and # auxiliaries

• Calculation: • P2P: Population being assessed/Provider FTE

15

Measuring Provider Capacity• Survey

– Paper / Web / Phone based• Statewide or targeted to service area• Local validation and input often requested

– FTE = 40 hours (excludes admin, research, etc.)• For sub-pop groups: hours adjusted for proportional service to

target group

• Medicaid Claims – Used for Low income designation

• Also need Sliding Fee counts (collected separately)

– Defined by CPT codes that equate to office visits– 1 year timeframe (retrospective)– May need to contact organizations that bill for providers

• Providers on J-1 visa waiver or NHSC obligation not counted

16

Population to Provider Ratio• P2P for HPSAs:

17

Discipline Geographic Population Groups or Geo with high needs

or insufficient capacity

Medicaid Claims

Method

Primary Care

3500:1 3000:1 5000 Claims = 1 FTE

Dental 5000:1 4000:1 4000 Claims = 1 FTE

Mental Health

30000:1 (Psychiatrist only)

9000:1 (CMHP including

Psychiatrists)

6000:1 (CMHP) & 20000:1 (Psychiatrists)

20000:1 (Psychiatrist only)

6000:1 (CMHP including

Psychiatrists)

4500:1 (CMHP) & 15000:1 (Psychiatrists)

4000 Claims = 1 FTE (allowed in SDMS)

Contiguous Areas (CA)Identify areas in all directions from defined Service Area and exclude as possible based on criteria:

18

Question Exclusion Criteria

Existing HPSA? Same type or greater

Significant Demographic Disparities?

Twice the portion in the socioeconomic group or plus 15% for percentages below 15

Physical barriers? Impassable areas, rivers, major highways, mountains, etc.

Excessively Distant? >30 miles or 40 minutes

Over-utilized? PC: P2P ratio ≥ 2,000:1DC: P2P ratio ≥ 3,000:1MH: P2P ratio ≥ 20,000:1 Psychiatrists

P2P ratio ≥ 3,000:1 CMHP and ≥ 10,000:1 Psychiatrists

Other Population Adjustments• Tourists - Tourists are non-residents who visit an area for a

minimum of 24 hours. – Tourist Count * Fraction of year present * 25%

• Seasonal Residents - Seasonal residents are those who maintain a residence in the area, but inhabit it only 2 to 8 months of the year. • Seasonal Housing Units * Avg. Household Size * Fraction of year present

19

Scoring• Ranks HPSAs based on degree of shortage for

resource allocation purposes• HPSA scores range from 1 to 25 for primary care

and mental health, and 1 to 26 for dental health • Four Factors:

– All disciplines use:1. Provider Ratio2. % Below Poverty3. Distance to NSC

– Fourth Factor:• PC = Infant Mortality Rate or Low Birthweight Rate• Dental = Fluoridation,• MH = Elderly Ratio, Youth Ratio, Alcohol Abuse

Prevalence, and Substance Abuse Prevalence

20

21

Scoring Calculations

PrimaryCare

DentalHealth

MentalHealth

Criteria Max Points Awarded

MultiplierTotal

Points Possible

Max PointsAwarded

MultiplierTotal

Points Possible

Max PointsAwarded

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

% of Population belowFPL

5 x 1 = 5 5 x 2 = 10 5

Travel distance/time to NSC

5 x 1 = 5 5 x 1 = 5 5

Infant Mortality Rate or Low Birth Weight

5 X 1 = 5

Water Fluoridation 1 x1 = 1

Ratio of children under 18 to adults 18-64

3

Ratio of adults 65 and older to adults 18-64

3

Substance abuse prevalence

1

Alcohol abuse prevalence 1

Max Score: = 25 = 26 = 25

Source: HRSA CRHCP: 998-50

Nearest Source of Care (NSC)

• Used for scoring only based on distance / travel time

• All Designations: Nearest source of care that is accessible care to the RSA’s population: closest by road travel AND is not in an existing HPSA AND is not inaccessible due to physical or socioeconomic

barriers or overutilization

• Other requirements by designation type

– Low Income: Must accept Medicaid

– Geographic High Needs: Must accept Medicaid OR Sliding Fee

– Geographic: No low income access requirements

22

NHSC and Scoring Criteria

• Minimum score determined by available resources:

– Loan Repayment: At sites with HPSA scores of 14 or above, applicants are eligible for up to $50,000 in loan repayment for an initial service commitment

– Scholarship: Through September 30, 2018, site must have a HPSA score of 17 or above for their discipline

23

Facility Designation

• Prisons

• Mental Hospitals

• Public / Non-Profit serving designated area

24

Facility Auto-HPSA Score• Process is in flux – proposed changes delayed

– Key debate is whether data should focus on total population or population served. Also whether to use separate scores per site.

• Previous/Current: – P2P and NSC are based on SDMS provider data (had been

PCSA data before)

– IMR/LBW was based on PCSA, now data in SDMS (CDC)

– Poverty based on Census

• Any site that is located in a regularly designated HPSA can use the HPSA score for that area/population group instead of the facility score

25

MUA/P: Medical Underservice• Medical Care Only – no Dental/Mental Health equivalents

• Index of Medical Underservice

– Component indicators:• Percent of Population at or below 100% Poverty

• Percent Population ≥ 65

• Infant Mortality Rate

• Primary care physicians per 1,000 Population

– Weighted values for each component

– Sum of values must be ≤ 62.0

• No renewals required

• No Contiguous Area Analysis requirement

• MUP Pop must still meet 30% requirement

26

27

What’s New?

• Federal Systems / Policies

– New Shortage Designation Management System (SDMS)

– Universal provider data management requirement

– Universal designation update

– Auto HPSA scoring modifications

*** No New Regulations Issued

• State Capabilities

– Statewide Provider Survey Updates

– Use of Medicaid Claims Data analysis

– Integrated GIS-based data platform

• Data Management and Geo-Spatial analysis28

Shortage Designation Management System (SDMS)

• Released in 2014 but not fully functional until last year• Relies on a combination of standardized federal and state data

sources • Provides an interface for updating provider data and a map-

based utility for defining designated areas

29

Federal Data

Providers

Providers Address from National Provider

Identifier (NPI)

Center for Medicare &

Medicaid

Industry Data State Data

Health Data

Infant Mortality Rate(IMR)

Center for Disease Control and Prevention

Low Birth Weight(LBW)

Population Data

Total Resident Civilian Population

Census Bureau (Census and ACS)

Population at Federal Poverty

Level

Ethnicity Populations (e.g., Hispanic, Asian,

American Indian/ Alaska Native)

Youth & Elderly Population in Service Area

Travel Data

Private Transportation Network

Environmental Systems Research

Institute

Data Points

Provider Attributes for HPSA FTE Calculation

State Primary Care Offices

(PCOs)

Other Populations (Medicaid, Homeless, Migrant Farmworker)

Fluoridation Rate

Alcohol & Substance Abuse Rates

Source: HRSA CRHCP: 998-50

Universal Provider Data Management• PCO now responsible for ‘validation’ of all

providers in the state, not just designated areas

– Process began with list based on the CMS National Provider Identification (NPI) file

– Validation of location(s) of care, hours, low income access, etc.

– Going forward will look at all new NPI registrants

• Impact will primarily be related to Pop:Providerratios for Auto-HPSAs going forward

30

National HPSA Designation Update• All existing designations were re-evaluated in

November 2017– September 30 deadline for provider data updates– Areas lost will not formally be withdrawn until 2018

Federal Register is published in Aug 2018 (status as of May)

– Contiguous Area issues not evaluated until 2020

• Multiple impact analyses run to highlight designations in danger and scoring changes– Additional data collection and service area analysis done

to preserve designations and scores where possible

• Final Impact for WY:– 3 Dental designations lost, all others retained– 15 scores increased, 13 scores decreased, 5 unchanged

31

Auto HPSA Scoring Modifications

• Process generally follows HPSA scoring approach– Auto HPSAs are multi-site facilities with no true resident

population or community characteristics

– General approach attempts to allow population-served by organization to be used as a substitute

• Existing process often results in out-of-date scores unless organization requests update

• New process changes default data sources and clarifies rescore process and data requirements

• First impact analysis in Aug. 2018. Implementation not until April 2019.

32

Data Sources and Approach

• Community Health Centers and Look-Alikes

– Patient Population data based on most recent Uniform Data System (UDS) submission

• Rural Health Clinics and Tribal/IHS

– Initial data based on overall community statistics

– Patient Population data can be submitted after initial run and used for re-scoring

• Factors eligible for update noted by * on following slides

33

Auto HPSA New Component Scoring

• Service Area– CHC/LAL: Area from which top 75% of patients are

drawn

– RHC/Tribal/IHS: 30 or 40 minute drive time polygon around site *

• Pop:Provider Ratio (up to 10 points PC & Dent, 7 points MH)

– All provider data now derived from SDMS system

– CHC/LAL: Low Income pop, Medicaid SFS FTE

– RHC/: Total Pop, All FTE *

– Tribal/IHS: AI/AN Pop, FTE serving AI/AN pop *

34

Auto HPSA New Component Scoring (cont)

• Poverty % (up to 5 points)

– CHC/LAL: Patients <100% FPL / Total Patients• Unknown FPL patients not removed

– RHC/Tribal/IHS: Pop <100% FPL in drive time service area *

• Nearest Source of Care (up to 5 points)

– CHC/LAL & RHC: Next nearest provider accepting Medicaid AND Sliding Fee + not overutilized

– Tribal/IHS: Next nearest provider serving the AI/AN Population + not overutilized

• Infant Mortality / Low Birthweight (up to 5 points, PC)

– All county-level CDC data based on location of sites

35

Auto HPSA New Component Scoring (cont 2)

• Fluoridation (up to 1 point, Dental)

– Local data only, default is 0

• Alcohol or Substance Abuse Rate (up to 1 point, MH)

– Local data only, default is 0

• Elderly or Youth Ratio (up to 3 points, MH)

– CHC/LAL: Based on patients (UDS)

– RHC/Tribal/IHS: Based on area pop (Census) *

36

Wyoming Statewide Provider Surveys• Universal provider surveys

– Practice site level capacity for each provider

– Telephone outreach and follow up

– Web based surveys with paper option

– Provider scope goes beyond designation focus

• Primary Care – 2017– MD, DO, NP, PA, and CNM

• Mental Health – 2018 (ongoing)

– PSY, CPSY, CSW, PNS, MFT, LPC

• Dental - 2019

37

Medicaid Claims-Based Capacity Analysis• Concept: Visit count/year = FTE

– Only officially allowed for Medicaid• PC = 5000 claims per FTE • Dental/Psych = 4000 claims per FTE

• Timeframe: Any 12 month period– Wait 4-6 months for claims to ‘settle’

• Visits defined by CPT codes – Primary care visits then selected based on provider

• Detail needed by provider and service site• Patient zip code collected

– Not used directly in designation– For origin/destination study (discussed later)

38

Advantages of Claims Based Capacity

• Statewide analysis– Including participating providers in neighboring

states

• High ratio vs average productivity produces lower FTE for claims vs hours– 3500/5000 ≈ 0.7 FTE for PC

• Easier and likely more accurate than survey

• Regular updates

• Automatically accounts for other factors– Age, dental auxiliaries, hours/leave/vacation

39

Caveats for Claims Based Capacity

• Retrospective assessment (1+ years old)

• Need to assure complete content

• Issues with ‘organization-level’ billing

– Connection to individual providers (for SDMS)

– Sufficient address/service differentiation in NPI

– Inability to differentiate/remove specialist and/or non-physician claims, NHSC, etc.

– Bundled claim codes

40

CPT Code Selections

• Primary Care:– Evaluation & Management

• New Patient: 99201-99205• Established Patient; 99211-99215

– Preventive Medicine• New Patient: 99381-99387 • Established Patient: 99391-99397

– HCPCS T1015: FQHC all-inclusive

• Dental:– Oral Evaluation: D0120-D0180

• Psychiatry:– Psychiatric Diagnosis: 90791-90792– Psychotherapy: 90832-90853– Now also use Med E&M Codes (99201-99215) with modifier

41

Additional Uses of Claims Data

• Define objective universal service areas

• Test strength/porosity of service area boundaries

• Identify pockets of need within service areas

• Compare access to care for different segments of the population

• Examine alternate metrics of need

– Vs. Population:Provider ratio

42

Claims Origin-Destination Matrix Claim counts by 5-digit zip code combinations

Origin = Patient Zip Code

Destination = Provider Zip Code

Identify ‘fractional’ and ‘preferred’ destination zips based on plurality of claims

Origin_Zip Destination_Zip Claims Total Origin Claims % Preferred

01001 01107 1410 3196 44.1%

01001 01001 265 3196 8.3%

01001 01089 243 3196 7.6%

01001 01085 182 3196 5.7%

01001 01103 168 3196 5.3%

01001 01109 147 3196 4.6%

43

Travel Time Analysis

Add Origin / Destination Travel time via GIS

Volume weighted mean travel time(by # of claims) for each origin zip

Calculation fractional travel times for combined service area

% > 30 Minutes, >40 Minutes, etc.

O/D Zip Codes Drivetime (min)

03031-03031 0

03031-03101 19.5

03031-03053 29.7

03031-01854 40.1

44

WY Medicaid PC - Primary Destination

45

Claims from March 2015 - Feb. 2016

WY Medicaid PC - Primary Destination Defined Service Areas

46

Claims from March 2015 - Feb. 2016

WY Medicaid PC - Mean Travel Time for Care

47

Claims from March 2015 - Feb. 2016

WY Medicaid Dental - Primary Destination

48

Claims from March 2015 - Feb. 2016

WY Medicaid Dental - Destination Defined Service Areas

49

Claims from March 2015 - Feb. 2016

WY Medicaid Dental - Mean Travel Time for Care

50

Claims from March 2015 - Feb. 2016

WY Medicaid Psychiatry - Primary Destination

51

Claims from March 2015 - Feb. 2016

WY Medicaid Psychiatry - Destination Defined Service Areas

52

Claims from March 2015 - Feb. 2016

WY Medicaid Psychiatry - Mean Travel Time for Care

53

Claims from March 2015 - Feb. 2016

Further Potential for Claims O/D Analysis

Examine Differential Access Patterns:

By Insurance Type or Plan/Network (APCD)

Stratify by age, other characteristics

Diagnosis-specific claim markers

Service-Specific Access:

Mammography, Dialysis, any service with clear billing codes

Provider Adequacy:

Overlay with base population (Pop/Provider ratio)

Identify where accessibility affects utilization

54

Questions?

Eric Turer

Senior Health Services Consultant

501 South St., Bow NH 03304

eturer@jsi.com | Phone: (603)573-3307

Keri Wagner

Healthcare Workforce & Primary Care Office Manager

6101 Yellowstone Road Suite 420

Cheyenne, WY 82002

keri.wagner@wyo.gov | Phone: (307)777-6512

55