1. Concepts for Assessing Primary Care Provider Capacity

2. 2 Question: How much primary care capacity is effectively available to a given population?

3. 3 Assessing Primary Care Supply/Capacity Goal: Quantify the actual level of primary care provider capacity available to a population. –Methods should correspond to the parameters used for estimating population-level need/demand for primary care

4. 4 Quantify Need/Demand (Visits for Benchmark, Age Gender Adjusted, Average Health Status) Adjust for Population Health Status (Increase if below avg. health status, decrease if above ) Quantify Supply (Visit capacity for appropriate primary care providers ) Scale(s) of Provider Adequacy/Shortage (Combined measure of Supply vs Demand ) Set Threshold(s) for HPSA Designation Assess Health Outcome Deficits/Disparities (Areas/Populations with persistently and significantly negative health indicators ) Assess Other Indicators of Med.Underservice (Nature/Indicators TBD) Scale(s) of Medical Underservice (Assessed separately or Integrated into an index) Set Threshold(s) for MUA/P Designation or

5. 5 Overview of Capacity Current HPSA/MUA approaches to capacity Potential approaches to measuring capacity going forward Key Decision Points –Types of providers to include –Methods for counting of provider FTE –Exclusion factors for providers –Translating FTEs into Visits –Other factors influencing access to providers –Claims/Visit based approach

6. 6 Current Designation Approach to Provider Capacity Same for MUP and HPSA –Primary Care Physicians Only: Specialties: FP, GP, IM, PED, OB/G Excludes NHSC obligated, J-1, and federally employed providers Excludes administration roles, inpatient/emergency, locum tenens, suspended license Interns and residents counted as 0.1 FTE –40 hour/week patient care basis for FTE, 1.0 FTE max Includes office, rounds, consults, lab & x-ray review Location specific

7. 7 Current Designation Approach to Provider Capacity- Accessibility Considerations Low income FTE = % service to Medicaid and sliding fee Medicaid & SFS based on survey of % of patients/practice Medicaid Method’ – 5,000 claims = 1 FTE Other information: Language/Interpretation High need (closed practice, wait times for new/established patient) Service to special populations

8. 8 Current Approach to Provider Capacity (cont.) On-line Designation Application System (ASAPs) –Populated with AMA data if no state data uploaded –State Data if available; usually licensure Other Sources for provider lists: –Association lists –Hospital admitting lists –Medicaid/Medicare lists –Yellow pages Survey of providers typically conducted Claims from state Medicaid departments

9. 9 Potential approaches: A.Estimate capacity based on individual provider characteristics B. Claims/Visits based assessment of capacity C. Other?

10. 10 A.Estimating Capacity Based On Individual Provider Characteristics Starts with a list of potential primary care providers –Potential sources as noted in current methods

11. 11 A.Considerations for Assessing Individual Provider Capacity Provider types/specialties to include FTE basis Exclusions Relative capacity Other access related characteristics Provider Data Issues and alternative sources Provider Back-out options

12. 12 Provider Type Definition Physician Specialties to Include as PCPs? –General Practice, Family Practice, Internal Medicine, Pediatrics, Obstetrics/Gynecology? Interns/Residents? Board Certified vs. Board Eligible? –Sub-Specialties within broader groups? Presence of a secondary specialty beyond primary care (i.e. IM + Cardiology) Geriatrics, Adolescent Medicine, etc. Obstetrics or Gynecology Only –Hospitalists? –General Surgeons?

13. 13 Provider Type Definition Additional Providers –Nurse Practitioners, Physician Assistants, Midwives? Certification type –PA vs PA-C –CNM vs CPM Specialty (similar but not same as physicians) State specific variants: Scope of Practice –MD oversight, prescriptive authority, referral/diagnosis Others? Community Health Aides and Practitioners? Alternative/ Holistic/Naturopathic medicine?

14. 14 Full Time Equivalent (FTE) Calculation Considerations Uniform Hourly Basis for Full Time –32,36,40 Hours? –Point in time vs. time period? Potential inclusions/exclusions –Rounds, Admitting/Discharging, Consults? Hospitalist available, Admitting privileges –Clinical documentation, QA, Consults, etc.? –Time spent ‘On-Call’? –Self assessed percentage primary care? –Hours paid vs. hours worked Vacation, CME? Maternity/Short Term disability leave? Location Specific (multiple practice locations)

15. 15 Potential Provider Capacity Exclusions Work Setting –Hospital Only, Gov./Military/VA facility, Corporate? –Urgent Care Centers? Retail clinics? –Institutional Providers (LTC, Prison, Schools)? Separate issue for facility designations NOTE – Federally-linked provider issue to be discussed separately Professional Activity –Practice Administration, Legal, Clinical Teaching, Research, Advocacy/Prof. Society, Other non-patient care? –Locum Tenens? Status –Retired, Disabled, Suspended or Restricted License, Temporary leave, etc.? –Age Adjustment / Aged out? Foreign Medical Graduates? –‘Consideration’ is a legislative requirement

16. 16 Other Attributes/Indicators of Capacity New Patients Accepted? –Overall vs. sub-population groups –Individual vs. practice –Restricted access (eg. closed panel managed care) Wait times? –Routine appointments –New vs. established patients –Wait time in office Turnover/Stability? Citizenship/Visa Status? Need to consider how to factor into capacity

17. 17 Options Regarding Counting of Designation Related Resources Goal: Recognize role of designations and related federal programs in supporting capacity –Full inclusion of capacity related to designations/ programs (could lead to undesirable ‘yo-yo’ effect) –Full exclusion of related capacity (could lead to false measure of actual access and potential over-allocation of resources) Considerations: –Full, partial, or no back-out –Eligible programs/providers (see next slide) –Separate tracking of back-out FTE by program –Different exclusions for each designation category

18. 18 Designation/Program Linked Resources Considerations for Excluding Capacity Designation Dependent (for provider placement) –National Health Service Corps –State Loan Repayment Program –J-1 / Conrad 30 / ARC Visa Waivers Designation Associated Locations –Federally Qualified Health Centers/CHCs –FQHC Look-Alikes –Rural Health Clinics –Medicare Incentive Payment Other Providers (no current designation linkage) –H1b Visa Waivers –Federally Employed –Tribal Contract/Compacts –Indian Health Service –Other Safety Net providers (free clinics, county health depts., etc.)

19. 19 Capacity for Sub-Populations Goal: To assess effective capacity available to sub-population groups Disparate access to care vs. the community overall Nature of eligible sub-population groups discussed separately Current Population Groups Designated –Low Income / Medically Indigent Currently % Medicaid and Sliding Fee Scale in practice Other considerations: SCHIP, state/local/federally subsidized insurance plans –Medicaid enrolled/eligible Currently % Medicaid in practice or Claims data –Linguistically Isolated / Non-English speaking Currently % providers/staff offering interpretation or linguistically appropriate care –Special Populations Homeless Migrant/Seasonal

20. 20 OPTION: Translating FTE into Visits? Value of visit-based capacity –Equates relative capacity of different providers –Equates FTE capacity to visit-based demand Use of productivity statistics (visits/FTE) –Average (Mean) –Median or other percentile (25 th, 75 th, etc.) Sources of productivity statistics –UDS (non-profit, underserved populations) –MGMA (private practices) Specificity –by specialty or by degree/profession Other Variants (frontier, special populations)

21. 21 UDS/MGMA Productivity Comparison

22. 22 Primary Care Provider Data Issues No data set is complete –Unclear if providers may be missing from lists –Missing/partial data for elements that do exist –Detailed data questions not routinely available Hours worked Multiple practice locations & apportionment Percent service to sub-population groups Closed practice, wait times, translation, etc.

23. 23 Data on Primary Care Providers FT/PT = Full Time/Part Time P= Partial Z= Zip Code RT = Retired Date File Received

24. 24 B. Estimating Capacity Based On Claim/Visit Records Starts with a database of insurance claims or other record of service –Individual provider capacity not necessary

25. 25 B. Claim/Visit-Based Capacity Analysis Goal: To define current capacity based on a count of primary care service visits from administrative data Potentially valuable alternative where: –All services of interest result in claims submitted to a central repository –Population covered by potential claims can be identified and counted –Primary care services/providers can be identified in the claims records –Claims can be attributed to a provider of known location and/or a point of service General approach described/validated in literature –Shah, B. 2007 – HSR; Withy, K. 2010 Ethnicity & Disease

26. 26 Potential Applicability of Claims-Based Capacity Potential Claim/Visit Based Data Sources –Medicaid (State level or CMS MAX files in 2011) –Medicare –All Payor claims databases (state level) –Evolving Health Information Exchanges Process –Define minimum criteria for useable data sets –Define specification for identifying/counting unique primary care encounters –Determine geographic aggregation to locate capacity –Determine ability to count/locate the related population –Claim/visit counts can be directly compared to population-based need defined based on visits

27. 27 Notes regarding Medicaid Analytic Extract (MAX) Derived from the CMS Medicaid Statistical Information System (MSIS) –Consists of Person Summary File & Claims Files –Access to files restricted to government and research New claim elements added in 2009 (available in Fall 2011) –Provider Taxonomy –National Provider Identifier (NPI) –Equivalent data available at the state level Provides potential national ability to identify: –Medicaid claims associated with each provider Place of Service codes can identify federal programs –Medicaid eligible population (zip code level, age groups) –Could provide method for baseline testing of Medicaid/ low-income designations nationally

28. 28 Applicability to Measuring Shortage Visit-based supply of actual primary care capacity can be compared to visit based ‘ideal’ demand for care by the population –Ratio / percentage –Visit gap / deficit Designation linked providers can be identified as attribute of designations for programmatic use and/or back-out Other attributes might be factored in –Closed practices, high turnover, etc.