Transcript Analysis of Ovarian Cancer Surgeries Using State Hospital
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 Studies School of Public Health, SUNY at Albany (518) 402-0250 http://chws.albany.edu
March 11, 2011
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 1
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 2
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 3
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 4
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 5
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 6
Trends in Physician Supply
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The Supply and Distribution of Community-Based Primary Care Physicians in New York is Changing Change in Community-based Primary Care FTEs, 2005 - 2009 Region Capital District Central NY Finger Lakes Hudson Valley Long Island Mohawk Valley NYC North Country Southern Tier Western NY Statewide Supply Per 100k 78 68 81 84 88 61 89 64 76 69 82 Change 8.0% -0.4% 10.8% -1.4% 0.3% -1.9% -1.5% 8.6% 7.2% 2.0% 0.7% March 2011 Source: New York Physician Re-Registration Survey, 2005-2009
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 9
Current Shortage Designations
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Primary Care HPSAs in New York
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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 12
There is One Current MUA and One Current MUP in Suffolk
•1 MUA serving a population of over 5,000
METHODS
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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 15
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 16
Data Sources for Developing RSAs
Medicare Medicaid Health plan association data from 11 major private insurers Data on the uninsured from community health centers 17
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) 18
Statewide, 317 Preliminary Primary Care RSAs Were Created Using this Methodology
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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 HPSA Rules Current Geographic Current Special Population, Medicaid # Qualified 82 155 Population 1,543,200 N/A Proposed 2008 Geographic 112 3,837,400 20
Long Island RSAs
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RSAs in Nassau
There are 20 RSAs in Nassau County 22
There are 18 RSAs in Suffolk County
RSAs in Suffolk
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Current Geographic HPSA Guidelines
Under current rules, 3 RSAs would qualify for primary care geographic HPSA designation serving a population of 45,000 0 geographic HPSAs currently in the region 24
Current Geographic HPSA Guidelines
Under current rules, 3 RSAs would qualify for primary care geographic HPSA designation serving a population of 40,000 0 geographic HPSAs currently in the region 25
2008 Proposed HPSA Guidelines
Under the 2008 proposed rules, 3 RSAs would qualify for primary care geographic HPSA designation 26
2008 Proposed HPSA Guidelines
Under the 2008 proposed rules, 3 RSAs would qualify for primary care geographic HPSA designation 27
Current Special Population Guidelines
2 RSAs would qualify for special population, Medicaid-eligible designation 28
Current Special Population Guidelines
1 RSA would qualify for special population, Medicaid-eligible designation 29
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.
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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 31
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 32
Assessing the RSAs
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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?
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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?
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RSAs in Suffolk
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