A New Methodology for Identifying Primary Care Rational Service Areas

1. A New Methodology for Identifying Primary Care Rational Service Areas Long Island Robert Martiniano, Project Director, CHWS David Armstrong, Ph.D., CHWS Beverly Grossman, CHCANYS Center for Health Workforce StudiesSchool of Public Health, SUNY at Albany (518) 402-0250 http://chws.albany.edu rpm06@health.state.ny.us March 11, 2011

2. Today’s Presentation Background on Shortage Area Guidelines Trends in Physician Supply HEAL 9 Project Overview Rational Service Area Methodology Long Island RSAs Feedback from Stakeholders

3. Current HPSA Guidelines • Health Professional Shortage Areas (HPSA) • Primary care, dental health, and mental health • Geographic, special population, and facility • Designation criteria • A defined rational service area • 3,500 to 1 population to provider ratio (3,000 to 1 for special populations or high need geographic) • Services deemed inaccessible in contiguous areas

4. Current MUA/P Guidelines • Medically Underserved Area or Population (MUA/P) • Primary care only • Geographic or special population • Designation criteria • A defined rational service area • Weighted score of 62 or less based on • Population to provider ratio • Percent of the population under 100% of the Federal Poverty Level • Percent of the population 65 years of age or older • Infant mortality rate • Governor’s Exceptions

5. What are Shortage Area Designations Used for? • HPSA Designations are used for: • National Health Service Corp placements • J-1 Visa Waiver placements • Doctors Across New York placements • 10% Medicare enhanced rate (primary care geographic) • Medically Underserved Area/Population are used for: • Federal 330 new sites or expansion funding • J-1 Visa Waiver placements • Doctors Across New York placements

6. Proposed 2008 Guidelines • Proposed 2008 Guidelines • Merged HPSA and MUA/P • Adjusted the population to account for • Age • Mortality • Race/ethnicity • Poverty • Population density • Eliminated contiguous area analysis if a state has a statewide set of rational service areas • Included midwifes, nurse practitioners, and physician assistants in the primary care provider count

7. HEAL 9 Health Planning Grant • Problem 1: The current approach used to identify and designate primary care shortage areas in New York is fragmented • Problem 2: New York is not prepared for potential changes in shortage area guidelines • Solution: In collaboration with CHCANYS, conduct a comprehensive statewide primary care assessment • Rational Service Area (RSA) development • Primary care provider data collection • Primary care capacity assessment

8. Trends in Physician Supply

9. The Supply and Distribution of Community-Based Primary Care Physicians in New York is Changing Change in Community-based Primary Care FTEs, 2005 - 2009 March 2011 Source: New York Physician Re-Registration Survey, 2005-2009

10. The View from 10,000 Feet: We Know What We Don’t Know • The extent to which NPs, PAs, and midwives provide primary care services • How many community-based primary care physicians provide care to underserved populations • How far people travel (beyond county boundaries) for primary care services • Impact of expanded access to health insurance on demand for primary care • How the denominator is changing – a smaller, but older population upstate

11. Current Shortage Designations

12. Primary Care HPSAs in New York

13. Nassau County Has One Current MUP Designation • Nassau and Suffolk counties have no current primary care HPSA designations. • Nassau has a MUP designation under Governor’s exception. Hold for map

14. There is One Current MUA and One Current MUP in Suffolk • 1 MUA serving a population of over 5,000 13

15. METHODS

16. Developing RSAs: Cluster Analysis • Used by the Economic Research Service of the U.S. Department of Agriculture to construct commuting zones based on 1980 and 1990 journey-to-work data • Adapted this methodology for primary care RSAs throughout the state by analyzing patient commuting patterns for primary care office visits

17. Comparison to Primary Care Service Areas (PCSAs) • PCSAs are a potential alternative to creating RSAs • Created by Goodman et al. (Dartmouth) • Used Medicare claims data to assign each zip code to a PCSA based on where the largest proportion of patients go for primary care

18. Data Sources for Developing RSAs • Medicare • Medicaid • Health plan association data from 11 major private insurers • Data on the uninsured from community health centers

19. Methodology • The basic unit of data analysis was patient care commuting flows between zip codes. • From each data set: • Patient residential zip code • Primary care physician zip code • In some datasets patients had a designated PCP • In other datasets, primary care visits identified by CPT codes and physician specialty were used to determine a PCP • Zip codes were combined based on commuting patterns using a cluster analysis • Zip codes were then translated into townships (rural areas) and census tracts (urban areas)

20. Statewide, 317 Preliminary Primary Care RSAs Were Created Using this Methodology

21. More RSAs Would Qualify Under 2008 Proposed Rules than Current Rules for Geographic Designations Current rules for geographic designations may not benefit New York State

22. Long Island RSAs

23. RSAs in Nassau There are 20 RSAs in Nassau County

24. RSAs in Suffolk There are 18 RSAs in Suffolk County

25. Current Geographic HPSA Guidelines Under current rules, 3 RSAs would qualify for primary care geographic HPSA designation serving a population of 45,0000 geographic HPSAs currently in the region

26. Current Geographic HPSA Guidelines Under current rules, 3 RSAs would qualify for primary care geographic HPSA designation serving a population of 40,0000 geographic HPSAs currently in the region

27. 2008 Proposed HPSA Guidelines Under the 2008 proposed rules, 3 RSAs would qualify for primary care geographic HPSA designation

28. 2008 Proposed HPSA Guidelines Under the 2008 proposed rules, 3 RSAs would qualify for primary care geographic HPSA designation

29. Current Special Population Guidelines 2 RSAs would qualify for special population, Medicaid-eligible designation

30. Current Special Population Guidelines 1 RSA would qualify for special population, Medicaid-eligible designation

31. MUA Designations Under Current Rules No RSAs in either Nassau or Suffolk counties would qualify for MUAs.There is current one Governor’s Exception designation in Nassau County.There are two MUA/P designations in Suffolk County.

32. Next Steps in the Project • Continue with local meetings • Develop and compare RSAs using the different insurance types, i.e., Medicaid, Medicare, commercial, and uninsured • Finalize methodology and/or RSAs

33. Looking Ahead: Using RSAs Create a more systematic and streamlined approach to the identification and designation of HPSAs and MUA/Ps Inform impact analyses for proposed changes to update HPSA and MUA/P methodologies Health reform statute requires ‘negotiated rule making’ for revisions to current methodologies Support local health planning efforts Inform state policies and programs

34. Assessing the RSAs

35. Questions to Consider When Assessing the Proposed RSAs • Do these RSAs seem reasonable based on your knowledge of the region? • Are there unique circumstances within your region that could affect travel patterns to primary care services, including: • Changes in the service delivery system (expansions or reductions) since 2007? • Physical barriers (highway construction, bridge closures, etc.)? • Changes in the availability of public transportation since 2007? • Special populations that may not have been considered in the assessment of commuting patterns? • Any other issues that could affect the travel patterns of individuals to primary care services?

36. RSAs in Nassau • Are there unique circumstances within your region that could affect travel patterns to primary care services, including: • Changes in the service delivery system (expansions or reductions) since 2007? • Physical barriers (highway construction, bridge closures, etc.)? • Changes in the availability of public transportation since 2007? • Special populations that may not have been considered in the assessment of commuting patterns? • Any other issues that could affect the travel patterns of individuals to primary care services?

37. RSAs in Suffolk