III. CALCULATING POPULATION TO PROVIDER RATIOS

# III. CALCULATING POPULATION TO PROVIDER RATIOS

## III. CALCULATING POPULATION TO PROVIDER RATIOS

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1. III. CALCULATING POPULATION TO PROVIDER RATIOS Primary Medical Care -------------------------------------------------- III-1

2. CALCULATING POPULATION TO PROVIDER RATIOS (PRIMARY MEDICAL CARE) Objective: Participants will understand how to: 1) Identify all primary medical care providers 2) Calculate full-time-equivalency (FTE) 3) Determine the population to provider ratios -------------------------------------------------- • for primary medical care geographic and population designations III-2

3. Population to Provider Ratios Needed for Designation(PRIMARY MEDICAL CARE) -------------------------------------------------- Contiguous Areas are overutilized if: > 2,000:1 1 - See Appendix V for additional information on calculating infant mortality rates 2 - See Appendix V for information on insufficient capacity Geographic Area:> 3,500:1 A rational service area: county or sub-county (MSSA) Geographic Area w/Unusually High Needs:> 3,000:1 • Arational service area plus one of the following: • a) More than 20% of the population has incomes at or below 100% of the Federal poverty level; or • b) More than 100 births per year per 1,000 women ages 15-44; or • c) More than 20 infant deaths per 1,000 live births1; or • d) Meets insufficient capacity criteria2 Population Groups: > 3,000:1 A rational service area plus meets the requirements of the specific designation category (e.g. low-income, homeless, etc.) III-3

4. POPULATION SIDE OF THE RATIO A. Geographic Area Designations B. Population Designations -------------------------------------------------- : ________________ III-4

5. A. Geographic Designations -------------------------------------------------- • Excludes: inmates or individuals in institutions (e.g. nursing homes, prisons, college dormitories, military installations, Native Americans on reservations, etc.) Resident Civilian Population = Total permanent population in the service area (non-institutionalized population) • Source: Must use 2005 Claritas Population Estimates, effective 2006. • Can add: • a)Migrant Farmworkers • Data from the 2000 Migrant and Seasonal Farmworker Enumeration Profiles Study, or other approved source (must include methodology) • Tourists • Formula : 0.25 X (fraction of year present) X (average daily number of tourists) Local data (must include methodology and length of stay) • c)Seasonal Residents • Those who maintain a residence in the area, but inhabit it for only 2-8 months per year. Census or local data (must include methodology) d)Homeless Local data (must include methodology). III-5

6. B. Population Designations -------------------------------------------------- Low-Income Population Number of individuals in the service area that are at or below 200% of the Federal poverty level • Must be > 30% of the population in the service are Source: 2005 Claritas Population Estimates • Medicaid-Eligible Population • Number of individuals in the service area that are eligible for Medicaid • Must have > 30% of the population in the service area with • incomes < 200% of the Federal poverty level • Source: State Medicaid Office Homeless Population Number of individuals in the service area that are homeless Source: 2000 census data, or local data (must include methodology) III-6

7. B. Population Designations Continued Migrant Farmworker Population -------------------------------------------------- Number of individuals in the service area who are migrant farmworkers adjusted for the fraction of the year they are in the service area. (Add seasonal farmworkers if appropriate) Source: State/local data & 2000 Migrant & Seasonal Farmworker Enumeration Profiles Study • Ex: Napa County, California • Agricultural Season = 4 months • 4/12 = .333 • Migrant Farmworker Pop = 5,659 • 5,659 X .333 = 1,884 • Total Migrant Farmworker Population = 1,884 Native American/Native Alaskan Number of individuals in the service area that are Native Americansor Native Alaskans Source: 2000 census data III-7

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10. 2005 Claritas Population Estimates (Dashboard) Source: HWCDD -Access Database III-11

11. PROVIDER SIDE OF THE RATIO -------------------------------------------------- : ____ III-12

12. STEPS -------------------------------------------------- • 1) Identify all primary care physicians in the area to be designated • 2) Determine the number of hours each primary care physician works in direct patient care (office and hospital inpatient) serving the population to be designated • 3) Calculate the FTE for each primary care physician serving the population to be designated • 4) Calculate the population to provider ratio III-13

13. STEP 1 -------------------------------------------------- Identify all primary care physicians in the area to be designated. III-14

14. List all primary care Doctors of Medicine (M.D.) and Doctors of Osteopathy (D.O.) who: -------------------------------------------------- 1) Provide direct patient care in the service area, and 2) Practice principally in one of the six primary care specialties: • General Practice • Family Practice • General Internal Medicine • Pediatrics • Gerontology • Obstetrics and Gynecology Do not include: • Physicians engaged solely in administration, research, or teaching • Hospital staff physicians involved exclusively in inpatient or emergency room care • Locum tenens serving less than 1 year (on contract) • Physicians who are suspended under provisions of the Medicaid-Medicare Anti- Fraud and Abuse Act for a period of 18 months or more • Mid-levels, Physician Assistants, & Family Nurse Practitioners III-15

15. Gather More Information about each provider: -------------------------------------------------- • Physicians who serve in the NHSC Scholarship or Loan Repayment Programs, including if it is a “federal” or “State” program. • Physicians who serve under a J-1 or H-1B waiver • Physicians who are Federal providers (e.g., Commissioned Officers at Indian Health Services or Bureau Of Prisons) • Include physicians who are planning on retiring but are still seeing patients • Note: Survey in “Step-by-Step Guidelines” outlines recommended questions III-16

16. Sources of Provider Data -------------------------------------------------- • State Licensure Lists • National, State, and Local Medical Association Directories • Local Hospital Admitting Physician Listings • American Osteopathic Association (AOA) Physician Listing • Medicare and Medicaid Practitioner Lists • Local Telephone Directory/ Yellow Pages • Commercially Developed Listings (CD-ROM) Use several of these sources to assure a complete listing of physicians is being used. III-17

17. STEP 2 -------------------------------------------------- Determine the number of hours each primary care physician works in direct patient care (office and hospitalinpatient) serving the population to be designated. III-18

18. Designation Types and Whom To Include in the Provider Count -------------------------------------------------- DESIGNATION TYPE: III-19

19. Providers -------------------------------------------------- Total Physicians:5 III-20

20. STEP 3 -------------------------------------------------- Calculate the FTE for each primary care physician serving the population to be designated. III-21

21. FTE Calculation -------------------------------------------------- For each physician, include the number of hours of direct patient care provided (office and hospital inpatient) in the service area: • 40 hours = 1.0 FTE • Every 4 hours (½ day) is counted as 0.1 FTE • A provider serving more than 40 hours a week is counted as 1.0 FTE • Each provider’s FTE is rounded to the nearest tenth of a percent prior to totaling • Examples: 0.875= 0.9 0.817= 0.8 • 0.83 = 0.8 0.85 = 0.9 • Interns and residents are counted as 0.1 FTE (40 hours = 0.1 FTE) Note: The FTE for low-income population designations is based on the average number of hours per week spent with Medicaid and Sliding Fee Scale (SFS) patients. It is not based on whether the provider is accepting new Medicaid patients. III-22

22. Adjustment of FTE if Hospital Inpatient Hours Not Available -------------------------------------------------- • Use for physicians whose office hours are < 40 and information on hours spent in inpatient care is not available • Multiply office hours X appropriate factor • Cannot exceed 1.0 FTE • If specialty information is not known then use the default which is 1.6. III-23

23. Include in survey, but reduce the following provider’s FTE to 0.0: -------------------------------------------------- • Physicians under contract with the NHSC Federal Scholarship or Loan Repayment Programs (This does not apply to physicians in the State Loan Repayment Program) • Other Federal providers (e.g., Commissioned Officers at IHS or BOP sites, etc.) • Physicians who are graduates of foreign medical school who are not citizens or lawful permanent residents (including those with J-1 or H-1B visas) • Note: • List these physicians in the application but adjust their FTE to 0.0. III-24

24. Do NOT reduce the following provider’s FTE: -------------------------------------------------- • All primary care M.D.s and D.O.s who provide direct patient care in • the service area, including those who: • Serve in StateScholarship or Loan Repayment Programs • Serve at Indian Health Clinics and are not Federal providers • Plan on retiring but are still seeing patients III-25

25. FTEs - Geographic Designation -------------------------------------------------- Total Physicians: 5Total FTE: 3.2 3 – Dr. Spock spends 10 hours/week doing research 4 – Dr. Scully chooses to work only 15 hours/week 5 – Dr. Zhivago has an unknown number of hospital inpatient hours so the adjustment factor is used 6 – Dr. McCoy spends full-time in administration III-26

26. FTEs - Low-Income Designation -------------------------------------------------- Total Physicians: 5 Total Low-Inc FTE: 1.6 7 – Dr. Zhivago has an unknown number of hospital inpatient hours so the adjustment factor is used III-27

27. Survey Physicians to Determine Their FTE -------------------------------------------------- • Survey all primary care physicians in service area • 2 additional attempts to contact • Minimum two-thirds response rate required • Average response rate applied to non-responders Calculation of Non-Responders Ex: Elk Grove, California - 20 providers 15 - respond to survey 5 - no response after repeated telephone calls Response rate 15/20 = 75% Total FTE for the 15 responders= 9.5 1) Divide FTE of responders (9.5) by the number of responders (15) for the average FTE of responders (.63) 2) Multiply number of non-responders (5) by the average FTE of responders (.63) for FTE of non-responders (3.16=3.2) 3) Add FTE of responders (9.5) and non-responders (3.2) for total FTE = 12.7 III-28

28. Estimate Medi-Cal FTE Using Claims Data (Low-Income Designations) -------------------------------------------------- Include all primary care physicians accepting Medi-Cal, even if they are not accepting new patients. 5,000 Claims (fee-for-service) = 1 FTE For Medi-Cal Managed Care counties, a survey is required to determine each provider’s percent of current caseload on Managed Care patients. III-29

29. STEP 4 -------------------------------------------------- Calculate the population to provider ratio. III-30

30. Population to Provider Ratios -------------------------------------------------- Resident/Civilian Population Ratio: Resident/Civilian Population = 20,900 Primary Care Physician FTE = 3.8 (20,900 / 3.8 = 5,500:1) Resident/Civilian Population (High Needs) Ratio: Resident/Civilian Population = 20,900 Primary Care Physician FTE = 6.9 (20,900 / 6.9 = 3,029:1) (100% Federal poverty level at 21.1%) Low Income Population (200% Poverty) Ratio: Low Income Population = 10,137 (49.47%) PC Physician Serving that Population = 1.6 (10,137 / 1.6 = 6,336:1) III-31

31. What To Include In The Population to Provider Ratio Primary Medical Care Section of Your Application -------------------------------------------------- Population • Total adjusted population • Source of data and methodology if using source other than Claritas List of Providers Include the Following for Each Provider: • Name • Location: Non-metro areas - name of town Metro areas – complete address with zip code, and CT if available • Degree (M.D. or D.O.) • Specialty (GP, FP, OB-GYN, IM, PEDS, Gerontology) • Average number of hours per week in direct patient care in the area • Inpatient care hours or adjustment to total hours • Percentage of practice that is Medicaid (for low-income and Medicaid-eligible designations) • Percentage of practice that is Sliding Fee Scale (for low-income designations) • FTE total for each provider rounded to the nearest tenth of a percent • Description of how information was obtained (sources, methods of gathering data) Totals and Ratio • Total number of providers • Total FTE • Population to provider ratio • Explanation of any high need indicators III-32

32. What NotTo Include In Your Application -------------------------------------------------- • Information on the weather or climate • Information on road conditions, construction, or number of avalanches • Personal statements of driving time • Average number of funerals • History of the early settlers of the area • Newspaper articles • Pictures of the mayor • General information on access issues that is not specific to the area or population • Copies of old applications III-33

33. Contiguous Area Resources -------------------------------------------------- III-34

34. Contiguous Area Resources -------------------------------------------------- Objective: Participants will understand how to identify contiguous areas, determine if they have resources, and if the resources are excessively distant, over-utilized, or inaccessible to the population of the area proposed for designation Purpose of Contiguous Area Analysis: To identify nearby sources of care and determine if they are inaccessible to the population in the proposed service area III-35

35. STEPS -------------------------------------------------- 1) Identify the boundaries of eachcontiguous area 2) Evaluate each area to determine availability of resources III-36

36. Identify the boundaries of each contiguous area -------------------------------------------------- • Identify on a map the boundaries and population center of theproposed service area • Determine the contiguous areas in all directions within 30 minutes from the proposed area’s population center • Map the boundaries of each contiguous area in all directions (North, East, South, & West) Boundaries The boundaries of each contiguous area may be based on: • Travel time (30 minutes) • Socio-economic/demographic characteristics • Established neighborhoods • Physical barriers • Designated HPSA • The boundaries of contiguous areas are often (not always) based on the same census delineation as the proposed area • Proposed service area = whole county • Contiguous areas = whole counties • Proposed service area = census tracts (MSSA) • Contiguous areas = census tracts (MSSA) III-37

37. PROCESS OF EVALUATING AVAILABILITY OF RESOURCES -------------------------------------------------- A) Check the HPSA list to determine if any of the contiguous areas are designated as HPSA and therefore considered inaccessible. If it is not inaccessible HPSA, then B) Determine if there are significant socio-economic/demographic disparities or physical barriers If there are not significant socio-economic/demographic disparities or physical barriers, then C) Determine if the contiguous area’s providers are located > 30 minutes away from the population center of the proposed area and are therefore inaccessibledue to excessive distance If they are not excessively distant, then D) Determine if the resources in the contiguous area exceed the population-to-provider ratio and are therefore over-utilized If they are not over-utilized, this area cannot be designated. (Consider a different kind of designation) III-38

38. A) Check the HPSA status of the contiguous areas and determine if this type of HPSA is inaccessible to the proposed area -------------------------------------------------- If the proposed service area is:Then the contiguous area is inaccessible if it is a: III-39

39. Determine if Significant Socio-economic/DemographicDisparities or Physical Barriers Exist -------------------------------------------------- Significant demographic disparities betweenthe population in the service area and the population in thecontiguous area which result in the population being isolatedfrom nearby resources (A 30% or more disparity between the population in the service area and the population in the contiguous area) Significant socio-economic disparities: 100% poverty rate or 200% poverty rate (A 30% or more disparity between the population in the service area and the population in the contiguous area) Significant physical barrier: mountains, large parks, bodiesof water, highways, railway yards, industrial areas, etc. which result in the population being isolated from nearby resources III-40

40. C) Determine If Providers Are Excessively Distant -------------------------------------------------- 1) Develop a list of providers in the contiguous area 2) Map their office locations 3) Determine the travel time from the proposed area’s population center to the contiguous area Providers > 30 minutes from the population center are excessively distant Primary Health Care: > 30 minutes Interstate Roads - 25 miles X 1.2 = 30 minutes Primary Roads - 20 miles X 1.5 = 30 minutes Secondary Roads - 15 miles X 2.0 = 30 minutes III-41

41. D) Determine If Providers Are Excessively Distant (continued) -------------------------------------------------- Inner Portions of Metropolitan Areas: Distance is based on time using public transportation during non- rush hour. Bus routes and schedules must be described (provide narrative description and include bus schedule if possible). (Use only if the service area has population greater than 20% @ 100% poverty) III-42

42. E) Determine if Contiguous Areas Are Overutilized -------------------------------------------------- • Calculate FTE - use same method as used for the proposed service area • If needed, survey providers and determine FTE serving the population. Use same surveying method as used for the proposed service area. • Explain how the information was obtained and calculated, and include population, total FTE, and population to provider ratio Population to Provider Ratios: PRIMARY HEALTH CARE:> 2,000:1 primary care physician III-43

43. Example Inner Portions of Metropolitan Areas Map Analysis: 45-55 -------------------------------------------------- III-44

44. Inner Portions of Metropolitan AreasIdentify the boundary of the proposed area using census tracts and identify the population center (the census tract in the proposed area that has the highest population) -------------------------------------------------- MSSA 78.2aaa – Watts/Willowbrook, Los Angeles County Largest population center C.T. 2408.00 III-45

45. Inner Portions of Metropolitan Area (Primary Care HPSA) -------------------------------------------------- Proposed Area: MSSA 78.2aaa – Watts/Willowbrook, Los Angeles County: Summary: Res./Civ. Pop: 86,197 White Pop: 19.11% Black Pop: 32.27% Hispanic Pop: 66.81% Below 200% Pov: 69.91% *Below 100% Pov: 39.48% 65 year or older Pop: 5.30% Infant Mortality Rate: 6.8% *High Need Indicator: 100% of Poverty Rate > 20% III-46

46. Inner Portions of Metropolitan Areas -------------------------------------------------- A) Determine boundaries of adjacent contiguous areas. Area 1 (N) - MSSA 78.2fff – Firestone/Florence Area 2 (NE) - MSSA 78.2ccc – Huntington Park Area 3 (E) - MSA 78.2ooo – Lynwood S./Paramount N. Area 4 (SE) - MSSA 78.2bbb – Compton East Area 5 (SW) - MSSA 78.2uuu – Athens/Harbor Gateway Area 6 (NW) - MSSA 78.2s – South Central Southwest B) Determine boundaries of non-adjacentcontiguous areas. Non-adjacent MSSAs are contiguous if their pop centers are within 30 minutes of each other. Public transportation/bus routes may be used (only in metropolitan areas) to determine travel time, if the applicant’s 100% Poverty Population is greater than 20%. III-47

47. Inner Portions of Metropolitan AreasIdentify the boundaries and population center of the proposed service area III-48

48. Proposed Area: MSSA 78.2aaa – Watts/ Willowbrook, Los Angeles County Summary: Res./Civ. Pop: 86,197 White Pop: 19.11% Black Pop: 32.27% Hispanic Pop: 66.81% Below 200% Pov: 69.91% Below 100% Pov: 39.48% 65 year or older Pop: 5.30% Infant Mortality Rate: 6.8 Area 1 (N) – MSSA 78.2fff – Firestone/Florence: (Inaccessible: Designated Primary Care HPSA) Summary: Res./Civ. Pop: 101,027 White Pop: 28.78% Black Pop: 17.68% Hispanic Pop: 80.58% Below 200% Pov: 68.64% Below 100% Pov: 35.83% 65 year or older Pop: 5.57% Infant Mortality Rate: 6.0 HPSA: Yes Inner Portions of Metropolitan Areas (Contiguous Areas) -------------------------------------------------- III-50