Panel Presentation Shortage Area Designations Larry Allen, Center for Rural Health Elizabeth 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 XXX Dental Care HPSA X Mental Health HPSA X X Geographic HPSA X XXX Population HPSA X XX 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 9

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,

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 11

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 13

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 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 UpdateFR NoticeFR Publish 2008Sept. 30, 2012Oct. 30, 2012NovemberJune 1, 2013July 1, 2013

HPSA Federal Register Notice Update Schedule HPSAs to be Updated PCO Due DateOSD 90 Day ReviewHPSA Find UpdateFR NoticeFR Publish 2008Sept. 30, 2012Oct. 30, 2012NovemberJune 1, 2013July 1, March 30, 2013June 30, 2013JulyJune 1, 2014July 1, December 31, 2013March 30, 2014June 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

HPSA Activity Adair Bath Nicholas -Withdrawn Bracken ????Breckinridge Ohio Caldwell – PWCarter Robertson Clay Crittenden Russell Elliott Estill – PWTodd Green – PWHarlan (partial) Washington Hart – PWJackson Wayne Jefferson Knox Wolfe - PW Larue Leslie Lewis Livingston – Withdrawn Logan Lyon Madison – PWMagoffin Marion McLean Meade ????Menifee Metcalfe Muhlenberg - PW

Recent Trends Overview of gains and losses for Sample designation profiles

HPSA Determination: Hart ItemsCriteriaValue Result Valid Rational Service AreaYesNoDoes Not Pass Designation Population< Pass Pop/FTE Ratio>= 3500:15053:1Pass 200% of PovertyNone50.21%Pass Overall Contig Area AvailabilityNoYesDoes Not Pass HPSA DeterminationDoes Not Qualify

HPSA Determination – Hart 2 TypeCriteria ValueScoring Table ValueWeighted Value Population/Provider Ratio 5053:148 Poverty Percent Low Birthweight Rate 71 1 Infant Mortality Rate Per 1000 Births 60 Travel Time (Minutes) 00 0 Travel Distance (Miles) 00 HPSA Greatest Need Scoring11 HPSA Degree of Shortage2 Physician Short UnderServed 10684

HPSA Determination – Hart 3 Contiguous Areas CA CA Name HPSA Name HPSA Categor y Availabl e CA In- accessib le Over Utilized Excessi vely Distant Sig Socio- Economi c Diff Other Access Barriers Pop/ Provider Ratio 100% Pov 200% Pov Travel Mile Travel Time (Mins) Travel Mode S - Barre n Coun ty NON E YesNo 1381: Priva te

HPSA Determination: Wolfe County TypeCriteria ValueScoring Table Value Weighted Value Population/Provider Ratio2399:100 Poverty Percent Low Birthweight Rate103 3 Infant Mortality Rate Per 1000 Births 111 Travel Time (Minutes)00 0 Travel Distance (Miles)00 HPSA Greatest Need Scoring7 HPSA Degree of Shortage Physician Short UnderServed1196 CACA NameHPSA NameHPSA CategoryAvailable CA In- accessible Over Utilized Excessively Distant Sig Socio- Economic Diff Other Access Barriers Pop/ Provider Ratio 100% Pov200% PovTravel Mile Travel Time (Mins) Travel Mode E - Magoffin County MagoffinCOUNTYNoYes No 3091: NE - Morgan County MorganCOUNTYNoYes No 4709: N - Menifee County MenifeeCOUNTYNoYes No 12682: W - Powell County PowellCOUNTYNoYes No 4613: Far WSW - Estill County EstillCOUNTYNoYes No 2513: SSW - Lee County Low Income - Lee POP-LINoYesNo 1805: SE - Breathitt County NONEYesNo 1078:

Panel Questions?