1. Medical Underserved Populations HRSA NRM 6.23.11

2. Preview MUA/P Criteria Factors indicative of the health status of a population group (disparities in health status) Ability of the residents of a population group to pay for health services (inability to pay/lack of affordability) Access to these health services (barriers access to care) Availability of primary care providers to residents of a population group (unavailable primary care providers) Today’s Proposal MUP Process Regular Simplified Streamlined HPSA Special Populations Process

3. Decision Points & Questions 1.MUP – 3 processes Original streamlined split into two: streamlined and simplified 2.Tiered approach/local option – allows for synergy with MUA process while also including population specific alternatives Does this approach work? 3.Criteria for local options/tier 3 Tight enough? 4.Some areas still under discussion Highlighted during presentation and addressed again at end 5.Impact testing We want to move forward – looking for thumbs up for testing purposes, not final decisions

4. MUP – Regular Process These groups need to demonstrate all four criteria Disparities in health status Inability to pay/lack of affordability Barriers to access Unavailable primary care providers Potential Groups Groups named in national reports or health care legislation because they are known to experience disparities in health care access, quality, coverage or service delivery. This includes, but is not limited to, the following groups: Health People 2020 - “Groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.” Other groups to consider include: Native Hawaiians, Incarcerated Populations, Immigrants and Refugees.

5. Criteria 1: Disparities in Health Status Tiered approach based on Social Deprivation Index (SDI)/Direct Health Status (DHS). Applicant would start with tier 1 and move to next tier (in order) ONLY if data is not available. Tier 1 - The applicant would seek to develop their SDI/DHS measure score based on an analysis of the SDI and DHS measures with valid national (e.g. ACS), state (e.g. CHIS) or local (e.g. county survey) data available at the local level that is specific to the population for which the MUP designation is being sought. Tier 2 – For those SDI/DHS measures for which the applicant is unable to data specific to the population, the applicant would use data on the SDI/DHS measures for the general population in the geographic area from which the specific population resides. Tier 3 – SDI as above (Tier 1 or 2); because DHS measures do not reflect the significant health disparities being experienced by some populations, the MUP process will allow some applicants to utilize other DHS measures. These measures must meet criteria (next slide).

6. Health Status – Tier 3 Direct Health Status Measure Criteria: Must be a direct health status measure that is recognized nationally and is associated with primary care. The applicant must produce quantitative data from a data source accepted by a state or federal agency charged with monitoring or intervening on health disparities such as (but not limited to) the IOM or Healthy People 2020. The data must demonstrate that the population for which the designation is being sought has a significant (defined by that agency) disparity in health when compared to the general population. Other?

7. Criteria 2: Barriers to Access Factors identified by barriers group would need to be demonstrated by the population. Specific barriers identified as well as a local option: Race LEP Hispanic/Latino Rural/Frontier Disabilities Ambulatory Sensitive Care Conditions/USOC? Other/Local Other/local measures are intended for population groups known to experience disparities in health care access, quality, coverage, or service delivery. Barriers could include but are not limited to: geographic; physical barriers; discrimination/bias based on sexual orientation, gender identity or HIV status; literacy; and cultural competence. Criteria for Other/Local under discussion in large group

8. Criteria 3: Inability to Pay Tiered Approach – similar to health status. The applicant must start with the first tier and move to the next tier only if the data is not available. For example, if there are ACS data available specific to their population group for both poverty and uninsured, they must use Tier 1. They may only move to Tier 2 if ACS data on one of the two factors are unavailable for their specific group. Finally, they may utilize Tier 3 only when ACS figures are not available on their group for poverty and uninsured. The applicant will not be allowed to move to a higher tier when data for the lower tier are available but do not prove the ability to pay criteria.

9. Inability to Pay - Tiers Tier 1 - Similar to MUP Regular criteria for Tier 1 Health Status, use the MUA criteria for “ability to pay” with data specific to the population based on inter-relatedness of uninsurance and poverty level. Tier 2 - Similar to MUP Regular criteria for Tier 2 Health Status, use the MUA criteria for ability to pay with a mix of data specific to the special population (where available) and data for the general population within the same geographic area where specific population data are unavailable. It is assumed this will most likely be the case when special populations have specific poverty level data but not specific information on those who are uninsured. Tier 3 – For population groups that don’t have data for either factor available through the ACS and may not have any source for figures on the number of uninsured within the group, this last option would allow special populations to qualify by presenting sufficient data related only to the poverty level for their group. Proof of Inability to Pay would need to meet criteria (next slide).

10. Inability to Pay – Tier 3 Proof of inability to pay criteria (Tier 3) 1.The data are from a recognized source for 100% of poverty level specific to the special population. 2.The poverty rate is at least 5% above the normative rate for the general population in the same geographic area as the special population application. May use local data. [More details in next slide]

11. Poverty Threshold Poverty threshold - 5% above the 100% national normative poverty rate. Current HPSA regulations consider an area/group to have “high need” if 20% or more are below 100% of poverty. At the time of new regulations development, the national normative poverty rate is 14.5% (2009 ACS estimate). Five percent above this 2009 national rate would match the current HPSA regulations 20% threshold. By setting a standard rather than a specific numerical threshold, the requirement can fluctuate as poverty rate increases or decreases over time. The standard poverty data source will be the ACS, but if data are not available, the group may cite a national data set supported by a federal agency (originally created for MUP Streamlined process), comparing poverty level to the ACS national norm for the same year (or group of years if ACS five-year roll-up estimates are utilized for the national norm). Although 100% of poverty might not be the best measure for ability to pay, this was chosen as the one ability to pay indicator most likely to be available for the special populations groups, which might be included.

12. Criteria 4: Unavailable Primary Care Providers Provider availability – primarily determined via survey Difficult to assess competence/ability to serve some populations. It may be that evidence for lack of provider capacity is documented in some datasets, literature or legislation. Other ways of doing this? Population count Local population count will take place in an area in which the population can both reasonably access the locations where services are provided and support the federal resources that might be assigned or allocated to serve that population. P2P Ratios If threshold/line, will adjust for populations (more discussion under HPSA)

13. Scoring and Testing In recognition of the unique characteristics of underserved populations, there will be flexibility in the scoring so that some groups may score high in one of the criteria and low in another, but still reach the qualifying threshold. (The scoring system will be similar to MUA scoring). Impact testing by sample population groups – e.g. LGBT, Native Hawaiians, low-income

14. MUP Appendix Local Data - specify of source, coverage year/s, geographic area, population group and methodology. Proxy Data – for instances where the regulations call for specific data related to the population for which the designation is sought (e.g., poverty) and where no such local RSA data are available, the applicant shall be allowed to submit proxy information if a strong relationship between the proxy population and the application population can be proven. Data used to justify such a relationship must show a strong correlation between the proxy population and the applicant population (i.e., a significant proportion of the applicant population also have the characteristics of the proxy population) and must meet the guidelines for local data including specification of: source, coverage year/s, geographic area, population group and methodology. Income-to-poverty ratios represent the ratio of family or unrelated individual income to their appropriate poverty threshold. Ratios below 1.00 indicate that the income for the respective family or unrelated individual is below the official definition of poverty, while a ratio of 1.00 or greater indicates income above the poverty level. A ratio of 1.25, for example, indicates that income was 125 percent above the appropriate poverty threshold” (U.S. Census Bureau, 2004).

15. MUP – Simplified Process Description - groups established by Department of Health and Human Services (HHS) legislation. These groups meet three of the four criteria at the national level (two by legislation and one using poverty data), thus waiving the need for justification at the local level. The fourth criteria must be demonstrated locally (details in next slide). Justification - it should not be necessary for applicants to repeat legislatively established justification that specific groups meet MUP criteria. Simplifying the process will save HRSA, PCOs and local applicants considerable time and resources. Groups - may include, but are not limited to: Ryan White Comprehensive AIDS Resources Emergency (CARE) Act, PL 101-381 Combating Autism Act of 2006 Developmental Disabilities Act The Traumatic Brain Injury Act of 2008 (P.L. 110-206) Disadvantaged Minority Health Improvement Act

16. MUP - Simplified Four Criteria Disparities in Health Status and Barriers to Access – documented through legislation (criteria on next slide) Poverty Rate - at least 5% above the normative rate for the general population in the same geographic area as the special population application (see prior discussion). Unavailable providers – Local population count will take place in an area in which the population can both reasonably access the locations where services are provided and support the federal resources that might be assigned or allocated to serve that population.

17. MUP - Simplified Legislation Criteria: The legislation must authorize a program that is administered by the Department of Health and Human Services. The legislation must name a specific and identifiable population. The legislation must authorize a program created for a specifically identified population to address disparities in health status in that population when compared to the general U.S. population. The legislation must authorize a program created to address at least one barrier to access to health care. Current and past legislation – under discussion Impact testing – legal review; sample populations represented by legislation to test.

18. MUP – Streamlined Process Description - e stablished MUP groups are assumed to meet all four criteria and only need to perform a local population count. Justification - i t should not be necessary for applicants to repeat well-established and accepted justification that specific groups meet MUP criteria. Groups Section 330 Populations - already named in statute (migrant and seasonal farmworkers, individuals experiencing homelessness, public housing residents). The Public Health Service Act Section 330 program legislation provides automatic MUP if awarded a special population Community Health Center grant. Members of Indian Tribes - American Indians and Alaskan Natives are unique populations who are members of separate, sovereign nations within the United States. U.S. government has promised these populations continual access to health care.

19. MUP - Streamlined Local population count will take place in an area in which the population can both reasonably access the locations where services are provided and support the federal resources that might be assigned or allocated to serve that population.

20. HPSA – Special Populations Special Population HPSA (“regular” process) The area in which they reside is rational for the delivery of primary care houses. (current language) Access barriers prevent the population group from use of the area’s medical care providers. Such barriers may be economic, linguistic, cultural or architectural, or could involve refusal of some providers to accept certain types of patients or to accept Medicaid. (current language) Change “refusal” to “the degree to which available providers serve that population” (current practice) Recognize that provider competence and quality of care are NOT addressed by this language. This is extremely difficult data to obtain, especially by self-report survey. We recommend that guidance be provided on survey development to get at provider competence. Other ways of doing this?

21. HPSA – Special Population Special Population HPSA (“regular” continued) Ratio 1:3000 (current threshold) If there is a new threshold set for the general population, we will adjust for special populations (current practice) If it is continuous, then we would like input as to where the MUP line is drawn. A separate threshold or line may be allowed if nationally representative data from a recognized federal source supports a lower P2P ratio for a given special population.

22. HPSA – Special Populations HPSA Special Population Groups (“streamlined”) Indians, Native Alaskans (currently named) Add Section 330 groups from Streamlined MUP process - migrant and seasonal farmworkers, individuals experiencing homelessness, public housing residents. Designation will not require P2P; HPSA scoring will determine distribution of resources (current practice) Simplified MUP groups will not be included.

23. Decision Points & Questions 1.MUP – 3 processes Original streamlined split into two: streamlined and simplified 2.Tiered approach/local option – allows for synergy with MUA process while also including population specific alternatives Does this approach work? 3.Criteria for local options/tier 3 Tight enough? 4.Areas still under discussion Disparities in Health Status – Tier 3 - more criteria? Inability to Pay – Tier 3 – include? Legislative Criteria – barriers? current/past? Measuring Provider Capacity – ideas? 5.Impact testing We want to move forward – looking for thumbs up for testing purposes, not final decisions