1. VII. Medically Underserved Areas (MUA) & Medically Underserved Populations (MUP) VII-1

2. MUA/MUP MUA/MUP Objective: Participants will understand: 1) The difference between MUAs & MUPs 2) The information required for a complete submission 3) How each factor is weighted and scored to determine a final Index of Medical Underservice (IMU) Score VII-2

3. Designation Requirements for Selected Federal Programs VII-3 Shortage Designation Option National Health Service Corps Federally Qualified Health Center Program Medicare Incentive Payment Rural Health Clinic Program J-1 Visa Waiver Primary Care HPSA (Area only)XXXX Primary Care HPSA (Population Only)X XX Dental Care HPSA (Area & Population)X Mental Health HPSA (Area only) XXX Mental Health HPSA (Population only) XX Facility HPSAXX Medically Underserved AreaXX X Medically Underserved PopulationXX State Governor’s Certified Eligible Area (for RHC purposes only) X (Not in CA)

4. MUA Criteria Origin: HMO program and Community/Migrant Health Centers (C/MHC) Measures the degree of underservice of an area (MUA) or a population (MUP) 1. Component: Rational Service Area (RSA) 2. Criteria and Weighted Values: a) [V1] Percent of Population at 100% Poverty b) [V2] Percent of Population > 65 c) [V3] Infant Mortality Rate (IMR) d) [V4] Primary Care Physicians per 1,000 Population 3) Index of Medical Underservice: Value must be < 62.0 VII-4

5. MUP Criteria 1. Component: Rational Service Area (RSA) 2. Criteria and Weighted Values: a) [V1] Percent of Population at 100% Poverty b) [V2] Percent Population > 65 c) [V3] Infant Mortality Rate d) [V4] Primary Care Physician serving the low-income pop (200% poverty level) per 1,000 low-income population 3. Index of Medical Underservice: Value must be < 62.0 VII-5

6. 1. Determine the Rational Service Area (use MSSA) 2.Assemble data a)Percent of the population at the 100% poverty level b)Percent of the population > 65 c)Infant mortality rate d)Primary care physicians per 1,000 population 3.Determine weighted values 4.Compute the Index of Medical Underservice ScoreSTEPS VII-6

7. Determine the Rational Service Area (use MSSA). STEP 1 VII-7

8. Types of MSSAs Medical Service Study Areas (MSSAs)  Whole County MSSA  Sub-County MSSA VII-8

9. Assemble data on: a)Percent of the population at the 100% poverty level b)Percent of the population > 65 c)Infant mortality rate (IMR) d)Primary care physicians per 1,000 population STEP 2 VII-9

10. Determine weighted values of: STEP 3 VII-10 a) Percent of the population at the 100% poverty level poverty level b) Percent of the population > 65 c) Infant mortality rate (IMR) d) Primary care physicians per 1,000 population population

11. Step 3a (V1) Percentage Population at 100% Poverty  Determine the percentage of the population in the area at the 100% poverty level  Use latest available data ( 2010 ACS Population Estimates )  Calculate 100% Poverty: Number at 100% Federal Poverty Level Civilian Population  Determine the weighed value (see table) 1 1 This value is the same for both MUAs and MUPs VII-11

12. Step 3a (V1) Percent Population at 100% Poverty Percent Below Poverty Weighted Value 025.1 0.1-2.024.6 2.1-4.023.7 4.1-6.022.8 6.1-8.021.9 8.1-10.021.0 10.1-12.020.0 12.1-14.018.7 14.1-16.017.4 16.1-18.016.2 Percent Below Poverty Weighted Value 18.1-20.014.9 20.1-22.013.6 22.1-24.012.2 24.1-26.010.9 26.1-28.09.3 28.1-30.07.8 30.1-32.06.6 32.1-34.05.6 34.1-36.04.7 36.1-38.03.4 VII-12

13. Step 3a (V1) Percent Population at 100% Poverty Percent Below PovertyWeighted Value 38.1-40.02.1 40.1-42.01.3 42.1-44.01.0 44.1-46.00.7 46.1-48.00.4 48.1-50.00.1 50 +0 VII-13 (continued)

14. Step 3b (V2) Percentage of Population > 65  Determine the percentage of the population in the area > 65 years old  Use the latest available data ( 2010 ACS Population Estimates )  Calculate percent > 65 years old: Number > 65 years old Civilian Population  Determine the weighted value (see table on next page) 1 1 This value is the same for both MUAs and MUPs VII-14

15. Step 3b (V2) Percent Population > 65 Percent of Pop >65 Weighted Value 0 –7.020.2 7.1-8.020.1 8.1-9.019.9 9.1-10.019.8 10.1-11.019.6 11.1-12.019.4 12.1-13.019.1 13.1-14.018.9 14.1-15.018.7 15.1-16.017.8 Percent of Pop >65 Weighted Value 16.1-17.016.1 17.1-18.014.4 18.1-19.012.8 19.1-20.011.1 21.1-21.0 9.8 22.1-22.0 8.9 22.1-23.0 8.0 23.1-24.0 7.0 24.1-25.0 6.1 25.1-26.0 5.1 VII-15 (continued)

16. Step 3b (V2) Percent Population > 65 Percent of Pop >65Weighted Value 26.1-27.04.0 27.1-28.02.8 28.1-29.01.7 29.1-30.00.6 30 +0 VII-16 (continued)

17. Step 3c (V3) Infant Mortality Rate (IMR)  Use the OSD available data (5-year average) or OSD-approved State Department of Health data Department of Public Health’s Center for Health Statistics website: http://www.cdph.ca.gov/certlic/birthdeathmar/Pages/default.aspx Use the IMR for the county  Calculate Infant Mortality Rate Number of Infant Death Number of Live Births  Determine the weighted value (see table on next page) 1 1 This value is the same for both MUAs and MUPs VII-17 x 1,000

18. Step 3c (V3) Infant Mortality Rate (IMR) Infant Mortality Rate Weighted Value 0-826.0 8.1-9.025.6 9.1-10.024.8 10.1-11.024.0 11.1-12.023.2 12.1-13.022.4 13.1-14.021.5 14.1-15.020.5 15.1-16.019.5 16.1-17.018.5 Infant Mortality Rate Weighted Value 17.1-18.017.5 18.1-19.016.4 19.1-20.015.3 20.1-21.014.2 21.1-22.013.1 22.1-23.011.9 23.1-24.010.8 24.1-25.09.6 25.1-26.08.5 26.1-27.07.3 VII-18 (continued)

19. Step 3c (V3) Infant Mortality Rate Infant Mortality Rate Weighted Value 27.1-28.06.1 28.1-29.05.4 29.1-30.05.0 30.1-31.04.7 31.1-32.04.3 32.1-33.04.0 33.1-34.03.6 34.1-35.03.3 35.1-36.03.0 36.1-37.02.6 Infant Mortality Rate Weighted Value 37.1-39.02.0 39.1-41.01.4 41.1-43.00.8 43.1-45.00.2 45.1+0 VII-19 (continued)

20. Step 3d (V4) Providers per 1,000 Population  Determine the FTE: MUA – All primary care physicians are counted MUP – All primary care physicians servicing the population group are counted Must collect inpatient and outpatient hours of the outpatient Doctors (not hospitalists)  Determine the population: MUA = civilian population MUP = number in that population group (e.g., low-income pop = pop at or below the 200% poverty)  Calculate Providers per 1,000 population: MUA: Total FTE 1 MUP: Total FTE Civilian Pop Pop to be designated  Determine the weighted value (see table) 1 All physician must be counted (including J-1 Visa physicians, NHSC physicians, etc.). For MUA designations, the HPSA adjustment factor for the FTE is not used. VII-20 X 1,000

21. FTEs - Geographic Designation 1 Dr. Liver is an NHSC loan repayment recipient, counted as 1.0 FTE 2 Dr. Spleen spends 10 hours/week doing research 3 Dr. Lung spends 15 hours/ week in administration Physician NameSpecialtyLocation of Practice/CT Hours of Direct Patient Care/Week FTE A. Liver, MD 1 General Practice86 N. Onion Street City, State, Zip 48 (48/40=1.2=1.0) 1.0 B. Spleen MD 2 Pediatrics103 Sanfgroid Dr City, State, Zip 30 (30/40=.75) 0.75 C. Heart, MDInternal Medicine777 Stopper Ave City, State, Zip 401.0 D. Kidney, DOOB-GYN3306 Stone Drive City, State, Zip 401.0 E. Lung, DO 3 Family Practice99 Airborne Blvd City, State, Zip 25 (25/40=.625) 0.625 Total Physicians = 5 Total FTE = 4.375=4.4 VII-21

22. FTEs – Low-Income Population Designation Physician NameSpec.Practice Location Direct Pat. Care Hrs/Wk FTE% of Medi -Cal % of Sliding Fee % of Low- Income Total Low-Inc FTE A. Liver, MDGP 86 N. Onion St City, State, Zip 481.064%15%79%0.79 B. Spleen MDPED 103 Sanfgroid Dr City, State, Zip 300.7535%8%43%0.3225 C. Heart, MDIM 777 Stopper Ave City, State, Zip 401.060%40%100%1.0 D. Kidney, DOOB/ GYN 3306 Stone Drive City, State, Zip 401.013%0%13%0.13 E. Lung, DOFP 99 Airborne Blvd City, State, Zip 250.6257%0%7%0.04375 Total Physicians = 5Total L- I FTE = 2.28625=2.3 VII-22

23. Step 3d (V4) Providers per 1,000 Population PC Physicians per 1,000 pop Weighted Value 0-.050.051-.1000.5.101-.1501.5.151-.2002.8.201-.2504.1.251-.3005.7.301-.3507.3.351-.4009.0 PC Physicians per 1,000 pop Weighted Value.401-.45010.7.451-.50012.6.501-.55014.8.551--.60016.9.601-.65019.1.651-.70020.7.701-.75021.9.751-.80023.1 Left Column – find the range which includes the ratio of primary care physicians per 1,000 population for the area being examined. VII-23

24. Step 3d (V4) Providers per 1,000 Population (continued) Providers per 1,000 pop Weighted Value.801-.85024.3.851-.90025.3.901-.95025.9.951-1.00026.6 1.001-1.05027.2 1.051-1.10027.7 1.101-1.15028.0 1.151-1.20028.3 1.201-1.25028.6 Over 1.25028.7 VII-24

25. STEP 4 Compute the Index of Medical Underservice Score (IMU). VII-25

26. Compute the Index of Medical Underservice Score The IMU Score is determined by adding the values of each of the four factors. V1 + V2 + V3 + V4 = IMU Score IMU < 62.0 Qualifies for designation as an MUA/MUP IMU > 62.0 Does not qualify for designation as an MUA/MUP VII-26

27. Time Saving Tips  Before surveying providers, check the IMU score of the first 3 variables  If V1 + V2 + V3 are > 62.0, the area will not designate as an MUA or MUP  If the IMU > 62, then review rational service area to determine if other boundaries would be appropriate  If not an MUA, check if area would designate as an MUP VII-27

28. MUA/MUP Exercise (Example) VII-28

29. VII-29

30. What to Include in the MUA/MUP Application VII-30

31. What to Include in the MUA/MUP Application (continued) VII-31 List of Primary Care Physicians:  Name  Location Non-Metro areas – name of town Metro area – address with zip code, CT if available  Degree (MD or DO)  Specialty  Average # hours/week of patient care in area  % of practice Medicaid (for low-income, Medicaid-eligible, and poverty population designations)  % of practice Sliding Fee Scale (for low-income, poverty pop designation)  Inpatient care hours  FTE total for each provider rounded to the nearest tenth of a percent  Description of how information obtained (source, method)

32. What to Include in the MUA/MUP Application (continued) VII-32 Primary Care Physician per 1,000 Population  Total FTE  Primary Care Physician per 1,000 Population  Calculation Other Variables  Percent at 100% Poverty  Infant Mortality Rate  Percent > 65  Source of Data IMU Score  Show weighted values for 4 variables  Show IMU Score  Do not submit applications for IMU > 62.0

33. VII-33 Proposed MSSA is 66a

34. The orange area is a designated MUA, and part of the designation is in MSSA 66a and part MSSA 63- because of this the whole designation can be thrown out VII-34

35. Calculate the IMU Score Calculate the Ratio of Population to Primary Care Physician STOP: Area Will Not Qualify Calculate the Percentage of Population Age 65 or Over Define Rational Service Area Calculate Percentage of Population with Income below the Poverty Level Determine Service Area Population Process Model for MUA Designation Follow arrows: Numbers are reference citations only. Refer to correspondingly numbered pages following for additional information on steps in numbered boxes 2 3 4 1 8 Calculate the Infant Mortality Rate 5 Determine Physician FTE 6 7 10 62.1 or Above APPLY FOR DESIGNATION 9 62.0 or Below VII-35

36. Calculate the IMU Score Calculate the Ratio of Low Income Population to Primary Care Physician Serving that Population STOP: Area Will Not Qualify Calculate the Percentage of Population Age 65 or Over Define Rational Service Area Calculate Percentage of Population with Income below the Poverty Level Determine Service Area Population Process Model for MUP Designation Follow arrows: Numbers are reference citations only. Refer to correspondingly numbered pages following for additional information on steps in numbered boxes 2 3 4 1 8 Calculate the Infant Mortality Rate 5 Determine Physician FTE 6 7 10 62.1 or Above APPLY FOR DESIGNATION 9 62.0 or Below VII-36