II. Rational Service Areas (HPSA - RSAs) II-1

HPSA - Rational Service Areas (HPSA - RSAs) Objective: Participants will understand: 1) The characteristics of a health professional shortage area/rational service area 2) The criteria used to determine if a service area is rational II-2

II-3 Health Professional Shortage Area (HPSA) Origin: National Health Service Corps (NHSC) (Measures the shortage of health professionals in an area) 1)Components a. Rational Service Area (RSA) b. Population to Provider Ratio c. Contiguous Area Analysis 2)Disciplines a. Primary Medical Care b. Dental Health Care c. Mental Health Care 3)Type of Designations a. Area b. Population Group c. Facility

Types of Rational Service Areas (Applies to all types HPSA and MUA/MUP designations) Medical Service Study Areas (MSSAs) – recognized by HRSA’s Office of Shortage Designation (OSD) as rational services areas  Whole County  Sub-County II-4

Rational Service Areas Cannot: 1) Overlap 2)Have more than one HPSA designation per discipline (e.g., geographic and low-income population) 3)Be smaller than a census tract 4)Exceed travel time between population centers 5)Have interior portions carved out II-5

“What is an MSSA?” II-6

MSSA Definitions Adopted by the California Healthcare Workforce Policy Commission on May 29, )Each MSSA is composed of one or more complete census tracts. 2)MSSAs will not cross county lines. 3) All population centers within the MSSA are within 30 minutes travel time to the largest population center. II-7

MSSA Definitions (Continued) Urban MSSA: II-8  Population range 75,000 to 125,000  Reflect recognized community and neighborhood boundaries  Similar demographic and socio-economic characteristics Rural MSSA:  Population density of less than 250 persons per square mile  No population center exceed 50,000 Frontier MSSA:  Population density of less than 11 persons per square mile

“Why MSSA?” II-9

Problems MSSAs Address California has 58 counties with wide ranging differences in size and population  U.S. Census Bureau recognizes whole counties as rural or urban.  Rural portions of counties such as San Bernardino, Riverside, Los Angeles, and Butte are declared as urban.  California’s cities have wide disparities in income and health status. II-10

Rationale for MSSAs Advantages of sub-county / sub-city areas  Better means of determining rural and urban areas in California  Better means of determining demographic/socio-economic differences and recognizing health disparities  Better means of identifying healthcare access in medically underserved communities II-11

Major Uses of MSSAs  U.S. Public Health Service recognizes MSSAs as “rational service areas” for purposes of determining Health Professional Shortage Areas (HPSAs) and Medically Underserved Areas/Medically Underserved Populations (MUAs/MUPs).  MSSAs are a principal component for display of large databases through OSHPD’s Geographic Information System (GIS).  MSSAs have the potential for assisting in needs assessment, health planning, and health policy development. II-12

Types of MSSAs  Whole County MSSA  Sub-County MSSA II-13

Whole County II-14

Sub-County II-15

Service Area Travel Calculation Mapping Source Used By SDB: Google Maps Primary Health Care Interstate Roads: 25 miles X 1.2 = 30 minutes Primary Roads (include surface streets): 20 miles X 1.5 = 30 minutes Secondary Roads (mountainous terrain or unpaved road): 15 miles X 2.0 = 30 minutes Dental and Mental Health Care Interstate Roads: 30 miles X 1.33 = 40 minutes Primary Roads (include surface streets): 25 miles X 1.6 = 40 minutes Secondary Roads (mountainous terrain or unpaved road) 20 miles X 2.0 = 40 minutes II-16

Mapping Sources Google: II-17

Primary Care 26 miles x 1.5 min = 39 minutes Dental & Mental 26 miles x 1.6 min = 41.6 minutes II-18

Mental Health Catchment Areas Since California does not have mental health catchment areas, MSSAs are used for purposes of designating mental health HPSAs. Service areas can be: 1) An MSSA 2) One or more MSSAs combined – travel time between each MSSA must be within 40 minutes. 3) Whole county – maximum population does not apply. II-19

Medical Service Study Area (MSSA) Reconfiguration Overview 20

A.MSSA Authorization and Definition B.Scheduling MSSA Reconfiguration Meetings C.MSSA Reconfiguration Step-by-Step D.Preparation of MSSA Motions E.MSSA Reconfiguration Adoption Process MSSA 21

 Song Brown Family Physician Training Act (1973): Creates California Health Manpower Policy Commission, which divides the state into sub- city and sub-county areas to determine areas of unmet need for physicians.  Garamendi Rural Health Services Act (1976): Requires Commission to determine which areas of the state are rural and which urban, and which rural areas are deficient in medical services. A. LEGISLATIVE AUTHORITY FOR MSSAs 22

A. MSSA = Rational Service Area MSSAs are adopted by the Federal Office of Shortage Designation (OSD) to be “rational service areas” (RSAs) for purposes of designating Health Professional Shortage Areas(HPSAs), Medically Underserved Areas and Populations (MUAs/MUPs). 23

California Healthcare Workforce Policy Commission (Commission) (Adopted May 29, 2013) A. MSSA Definitions 1.Each MSSA is composed of one or more complete census tracts. 2.As a general rule, MSSAs are deemed to be “rational service areas (RSAs)” for purposes of designating HPSAs, MUAs/MUPs. 24

A. MSSA Definitions Notwithstanding the general rule, an applicant for a HPSA, MUA, or MUP designation, for purposes of determining an RSA, may substitute Minor Civil Divisions (MCDs) for MSSAs in any of the following circumstances: a) Where an MSSA is comprised of a whole county with a single census tract and where the county contains more than one MCD. 25

A. MSSA Definitions (Continued) b) Where an MSSA is based on a single 2010 census tract which comprises all or part of two or more previous MSSAs whose boundaries were based on 2000 census tracts, block groups, or any other geographical unit established by the U.S. Census Bureau. c) Where the Commission has established any other rule for substituting MCDs for MSSAs. 26

A. MSSA Definitions (Continued) 3.MSSAs will not cross county lines. 4.To the extent practicable, all census- defined places within the MSSA are within 30 minutes travel time to the largest population center within the MSSA, except in those circumstances where meeting this criterion would require splitting a census tract. 5.To the extent practicable, areas that, standing alone, would meet both the definition of an MSSA and a Rural MSSA, should not be a part of an Urban MSSA. 27

A. MSSA Definitions (Continued) 6.Any Urban MSSA whose population exceeds 200,000 shall be divided into two or more Urban MSSA Subdivisions. 7.Urban MSSA Subdivisions should be within a population range of 75,000 to 125,000, but may not be smaller than five square miles in area. If removing any census tract on the perimeter of the Urban MSSA Subdivision would cause the area to fall below five square miles in area, then the population of the Urban MSSA may exceed 125,

A. MSSA Definitions (Continued) 8.To the extent practicable, Urban MSSA Subdivisions should reflect recognized community and neighborhood boundaries and take into account such demographic information as income level and ethnicity. 29

A. MSSA Definitions (Continued) 9.Rural Definitions: A rural MSSA is an MSSA adopted by the Commission, which has a population density of less than 250 persons per square mile, and which has no census defined place within the area with a population in excess of 50,000. Only the population that is located within the MSSA is counted in determining the population of the census defined place. 30

A. MSSA Definitions (Continued) 10. Frontier Definition: A frontier MSSA is a rural MSSA adopted by the Commission which has a population density of less than 11 persons per square mile. (Any MSSA which is not a rural or frontier MSSA is an urban MSSA.) 31

B. SCHEDULING MSSA MEETINGS 1.Develop List of all Counties Where MSSA Boundaries Need to be Addressed: CRITERIA Latest Census Shows Urban MSSAs that do not meet established population ranges. Previously rural MSSAs that no longer meet definition of “rural”. Previously frontier MSSAs that no longer meet definition of “frontier” Community stakeholders petition for redrawing of MSSA boundaries. 32

LOGISTICS 2.Establish Draft Schedule of MSSA Community Meetings in Such Counties 3.Confirm date, time and place for each MSSA Community Meeting 4.Locate site for meeting 33

ESSENTIAL CONTACTS 5.Establish , Phone & Address Lists: Local health officers All community health centers, county clinics, rural health clinics, Indian health clinics, teaching hospitals, Song-Brown training programs, and area health education centers located in the county California Healthcare Workforce Policy Commission 34

ESSENTIAL CONTACTS STATEWIDE ORGANIZATIONS: California Primary Care Association Statewide Area Health Education Centers California State Rural Health Association California Medical Association California Dental Association California Mental Health Association 35

TIMELINES Two Weeks Prior to Meeting: Agenda Summary of census data by existing MSSA Maps of existing MSSAs Power-point presentation 36 Day of Meeting: Sign-In Sheet Draft Support letters Meeting Documents

DAY OF MEETING Use of GIS Software, “districting tool” Previous MSSA configuration Latest census tract boundaries Latest population and socioeconomic data Latest counts of primary care physicians practicing per census tract Geographic features (highways, small streets, topography, natural features) Boundaries of presently recognized urban, rural and frontier areas Federal and state designated underserved communities 37

Once consensus (or substantial agreement) among the stakeholders has been reached on MSSA reconfiguration, then OSHPD will prepare a draft motion for the California Healthcare Policy Commission, which will be circulated among the stakeholders in the county If further changes are proposed by stakeholders following scheduled community meetings, OSHPD staff will attempt to determine whether there is a consensus for the revisions. If so, the draft motions will be revised. DAY OF MEETING 38

Changes to the boundaries of MSSAs can only be made through motions adopted by the California Healthcare Workforce Policy Commission. Any such motions will be agenda items of the Commission and should be accompanied by letters of support from community officials and stakeholders. DAY OF MEETING 39

All MSSAs are numbered. Those MSSAs that are divided into urban MSSA subdivisions (i.e., urban areas over 200,000 population) use the MSSA number, followed by letters, a, b, c, d..... aa, bb... aaa, etc. When new urban MSSA subdivisions are created, the succeeding urban MSSA subdivision with the greatest population of the original subdivision will retain the original subdivision’s letter. New MSSA subdivisions will receive the next available letters in alphabetical order. C. PREPARATION OF MSSA MOTIONS 40

A census tract is moved from one MSSA to another by means of a motion that follows the following formula: “Transfer the following census tract(s) from MSSA x (old name of MSSA x) to MSSA y (old name of MSSA y) “The resulting MSSA x is as follows: x (new name of MSSA x), consisting of census tracts: (all census tract numbers in new MSSA) “The resulting MSSA y is as follows: y (new name of MSSA y), consisting of census tracts: (all census tract numbers in new MSSA)” MSSA MOTION STYLE 41

Motions follow the numerical and alphabetical order of the “resulting MSSAs” Motions importing census tracts from other MSSAs into MSSA x come first, in numerical and alphabetical order. Motions exporting census tracts from MSSA x to other MSSAs come afterward, in numerical and alphabetical order.  Motions moving census tracts appear only once in a sequence of motions, at the earliest point numerically and alphabetically. MSSA MOTION STYLE 42

If there is no change in the geographic area comprising an MSSA (e.g., all parts of the 2000 census tracts are congruent with the 2010 MSSA), and no change in the MSSA name, the following convention is used: “Confirm the boundaries of MSSA z, as follows: z (name of MSSA z), consisting of census tracts: (all census tract numbers in MSSA)” For a change in name only, use: “Confirm the boundaries of MSSA z, renamed, as follows:” MSSA MOTION STYLE 43

Changes to the boundaries of MSSAs can only be made through motions adopted by the CHWPC. Any such motions will be agenda items of CHWPC and should be accompanied by letters of support from community officials and stakeholders. D. MSSA Reconfiguration Adoption Process 44

Questions? 45