Shortage Designations

And

Rural Health Clinics Presented By

Chris Workman, MASW

Steve Salt, MBA

What Are Federal Shortage Areas? A determination of where limited federal resources

may be placed.

Shortage Area determinations are NOT comparable to business sector/private sector analysis of provider need, as the threshold for federal resources is set at least twice as high as recommended in both scientific literature and business analysis of providers.

TYPE OF DESIGNATIONS Primary Care, Dental, or Mental Health – Health Professional Shortage Areas (HPSAs)

a. Geographic

b. Geographic High Need

c. Population (low income, migrant, Medicaid, homeless, etc.)

d. Facility (federal/state correctional/youth facilities, mental health hospitals, etc.)

e. Automatic (all FQHCs and RHCs)

TYPES OF DESIGNATIONS Primary Care – Medically Underserved Areas (MUA)

Involves application of the Index of Medical Underservice (IMU) to data on a service area to obtain a score for the area. The IMU scale is from 0 to 100, where 0 represents completely underserved and 100 represents best served or least underserved. Under the established criteria, each service area found to have an IMU of 62.0 or less qualifies for designation as an MUA. Criteria assessed: ratio of primary medical care physicians per 1,000 population infant mortality rate percentage of the population with incomes below the poverty level percentage of the population age 65 or over.

TYPES OF DESIGNATIONS Primary Care – Medically Underserved Population

(MUP) This involves application of the Index of Medical Underservice

(IMU) to data on an underserved population group within an area of residence to obtain a score for the population group.

Population groups requested for MUP designation are those with economic barriers (low-income or Medicaid-eligible populations), or cultural and/or linguistic access barriers to primary medical care services.

IMU score must be less than 62.0

How Do You Create Shortage Areas?

What Can You Get with a Shortage Designation?? Depending on the federal fiscal year allocations, up to 34-36 federal programs

use shortage designations.

Shortage Designation Option

National Health

Service Corps

Federally Qualified Health Center Program

CMS Medicare Incentive Payment

CMS Rural Health Clinic

Program

J-1 Visa Waiver

Primary Care HPSA X X X X

Dental Care HPSA X

Mental Health HPSA X X

Geographic HPSA X X X X

Population HPSA X X X

Facility HPSA X X

Exceptional MUP X X

Medically Underserved Area

X X X

Medically Underserved Population

X X

State Governor’s Certified Shortage Areas X X

WHERE ARE SHORTAGE AREAS HPSA and MUA/P Find

http://hpsafind.hrsa.gov/

CHFS OIG maintains the list of currently licensed RHCs (file must be filtered in Excel for RHC).

http://chfs.ky.gov/NR/rdonlyres/3C93BB5E-14F5-43E5-AC8D-9AF0A7E6FF36/0/MiscellaneousDirectory.xls

Mapping of Shortage Areas

One of the most frequently asked questions to HRSA and the Primary Care Office (PCO).

Unfortunately, HRSA nor the PCO have a way to easily provide mapping of shortage areas.

Part of the issue is the volume of designations, overlapping of types of designations, and service areas that aren’t traditional (not census tract or county based).

Even when required for internal purposes, the PCO has to create these maps by hand.

Current RHC Distribution

19 tte Development LLC. All rights reserved 19 tte Development LLC. All rights reserved

PCP Need – Medicaid Expansion & HBE View

Accounting for Medicaid expansion and the HBE, PCP need across the

Commonwealth increases to 256 FTEs at the highest end of the range. This view incorporates all 640,000 currently uninsured, which includes both additional

Medicaid and premium assistance. Of the 256 FTE need, 63% comes from rural

counties. Note: this is the worst-case scenario for Medicaid PCP need.

Kentucky-Wide PCP Need – 2012 (Excludes Surpluses)

With expansion, Bullitt and Spencer will each require 11 additional PCP FTEs

It appears that Medicaid

expansion will not have a large impact on the overall Eastern Kentucky need

With Medicaid expansion, the need in these 8 counties rises by 42% to a total of 51 PCPs

211Assumes average model retirement age of 65 and graduation from medical school at age 26 Copyright © 2012 Deloitte Development LLC. All rights reserved 211Assumes average model retirement age of 65 and graduation from medical school at age 26 Copyright © 2012 Deloitte Development LLC. All rights reserved

Physician Retirement Risk by geographic distribution

Using the data field Graduation Year, we can estimate physician age, and as a result, retirement risk. We have incorporated this estimated age field into the

modeling tool, which yields the below view of potential physician retirement risk.

Average Estimated Physician Age and Retirement Risk by County - 2012

# Average Physician Age (estimate)

Not In a Shortage Area? Special review requests to assess an area may be made to

the PCO. But HRSA requires that each state review existing shortage

areas prior to developing new area.

The PCO will try to fit in a special review request as we can, but there are no guarantees.

NEW – Effective approximately September 1, 2014 HRSAs new shortage review process will require assessment of providers approximately 6 months or more prior to the actual review. They are also creating review “cohorts” that will also limit when each type of shortage area can be review.

Even after the PCO review and submission, it will still take at least 3 months for HRSA to approve/deny.

So PLANNING is a must!!!

NUANCES • The Primary Care Office (PCO) analyzes the data and

submits to HRSA using a federal data and geomapping system. HRSA does not always agree with our determination and

justification. They WILL reject applications under consideration.

• HPSAs are required to be reviewed EVERY 4 years.

• MUA/Ps currently do not have to be re-reviewed, but that is expected to change. We have updated many MUAs to enable RHC applicants

to be come established under an MUA. But we do expect HRSA will eventually require MUA/P updates.

POSSIBLE FUTURE IMPACTS

• NEW – Effective approximately September 1, 2014 HRSAs new shortage review process will require assessment of providers approximately 6 months or more prior to the actual review. They are also creating review “cohorts” that will also limit when each type of shortage area can be reviewed.

POSSIBLE FUTURE IMPACTS • HPSA Regulation Changes

Section 5602 of the ACA requires updating the federal shortage designation regulations.

Deadline was supposed to be approximately 1 year after ACA passed, but held due to ACA litigation.

Unknown when or what will be in the new regulations, but we expect:

Inclusion of mid-levels (APRNs/PAs) in the formula.

Possibility that MUA/P designations will have to be reviewed (or they may be eliminated in lieu of an all in one type of new designation).

POSSIBLE FUTURE IMPACTS • RHC Regulation Changes?? CMS and HRSA have been attempting to

have the RHC Regulations Updated The Balanced Budget Act of 1997 (BBA) authorized CMS to

remove from the RHC program clinics that do not meet location requirements. In 2005, OIG recommended that CMS promulgate regulations to implement the BBA. However, CMS has yet to promulgate the final regulations. As a result, RHCs that no longer meet eligibility requirements continue to receive enhanced Medicare reimbursement.

HHS CMS OIG 2014 Workplan http://oig.hhs.gov/reports-and-

publications/archives/workplan/2014/Work-Plan-2014.pdf

PCO RESPONSES TO POSSIBLE IMPACTS

Development of a Pre-defined Rational Service Area (PRSA) Plan to HRSA this year. A PRSA Plan in theory will allow the PCO to use our own

defined variables to develop shortage areas.

And may also allow us to remove the requirement to review contiguous area.

Governor’s Certified Shortage Area Development After a PRSA Plan is approved by HRSA, we hope to begin

development of a Governor’s Shortage Area.

A Governor’s Shortage Area is specifically for RHC maintenance and would allow Kentucky to hopefully maintain older RHCs should CMS implement a new regulation.

Shortage Designation Contacts Steve Salt, MBA

stever.salt@ky.gov 502-564-8966, ext. 4010

Lynn Ann Bishop, BA Lynn.Bishop@ky.gov 502-564-8966, ext. 4011