Concepts for Assessing Primary Care Provider Capacity

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Question:How much primary care capacity is

effectively available to a given population?

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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

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Quantify Need/Demand(Visits for Benchmark, Age Gender Adjusted,Average Health Status)

Adjust for PopulationHealth Status

(Increase if below avg. healthstatus, decrease if above )

Quantify Supply(Visit capacity for appropriate

primary care providers )

Scale(s) of ProviderAdequacy/Shortage(Combined measure of

Supply vs Demand )

Set Threshold(s) forHPSA Designation

Assess Health Outcome Deficits/Disparities(Areas/Populations with

persistently and significantlynegative health indicators )

Assess Other Indicatorsof Med.Underservice

(Nature/Indicators TBD)

Scale(s) of MedicalUnderservice

(Assessed separately or Integrated into an index)

Set Threshold(s) forMUA/P Designation

or

or

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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

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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

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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

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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

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Potential approaches:

A. Estimate capacity based on individual provider characteristics

B. Claims/Visits based assessment of capacity

C. Other?

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A. Estimating Capacity Based On Individual Provider Characteristics

• Starts with a list of potential primary care providers– Potential sources as noted in current methods

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A. Considerations for AssessingIndividual 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

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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?

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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?

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Full Time Equivalent (FTE) CalculationConsiderations

• 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)

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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 designationsNOTE – 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

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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

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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

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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.)

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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

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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 (25th, 75th, 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)

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UDS/MGMA Productivity Comparison

(n)Mean

Productivity (n)Mean

ProductivityFamily Physicians * 4,260 3,768 540 3853 102%General Practitioners 381 3,915 N/AInternists 1,545 3,670 2103 3533 96%Obstetrician/Gynecologists 864 3,535 957 2917 83%Pediatricians 1,764 3,952 1596 4633 117%Other Specialty Physicians 310 3,191 N/A

Total Physicians 9,125 3,752 N/ANurse Practitioners** 3,389 2,865 487 2546 89%Physician Assistants** 1,881 3,162 482 2932 93%Certified Nurse Midwives 489 2,496 75 1401 56%

Total Mid-Levels 5,758 2,931 N/A

* with OB in MGMA** also available by specialty in MGMA

N/A

Not Reported

MGMA / UDS Prod. RatioBased on 2009 data

UDS MGMA

N/AN/A

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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.

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Data on Primary Care Providers

• FT/PT = Full Time/Part Time

• P= Partial• Z= Zip Code• RT = Retired• Date File

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Source AMA w/CMS ACNM AANP AANP AAPA

Year 2007 2006 2009 2010 2010 2010

Unduplicated Provider Identifier Physical Address

Address Type Identifier (Practice/Home/Mailing) One Practice Location Address ? P

Multiple Practice Location Addresses Z Percent allocation at each practice location Z hours

Hours or Percent time worked (Primary Care) FT/PT Overall Work Setting (Office, Hospital, LTC, etc)

Federal or Military Employment Date of Birth/Age Year Year

Practice Status (Active, Retired, etc.) RT Major Professional Activity (Clinical, teaching,

research, admin, etc.)

Primary Speciality N/A Secondary Specialty N/A

Board Certified

Content

Dataset

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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

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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

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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

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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

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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.