Goal: Select the most promising model for geographic HPSA designation to fully test

1. Goal: Select the most promising model for geographic HPSA designation to fully test July 20, 2011 1

2. The opportunity to directthis process is now. The time for big decisions has come. 2

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4. July 2011 NRMC Meeting GEO HPSA 4

5. Other Ways to Designate GEO HPSA 5

6. A modest proposal for decision making • the burden on the applicant should be reasonable and as simple as possible • there should be an evidence basis for decisions the committee makes GEO HPSA 6

7. A modest proposal for decision making • the method should have acceptable performance in that it meaningfully identifies and orders the areas of need • the consequences to existing safety-net providers and the communities they serve should be considered in the outcome REASONABLE EVIDENCE BASED GEO HPSA

8. Important Considerations • The results are for geographic HPSAs only • Based on PCSAs • Provider data over-counts FTE • Consequences for Medicare Bonus cannot be ignored • Total designated population cannot be ignored • Results are based on test thresholds only REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES GEO HPSA 8

9. MEDICARE BONUS TOTAL POP DESIG TEST THRESHOLDS Geographic HPSA Models * Unit of analysis: Counties, Primary Care Service Areas and Selected State RSAs. REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES GEO HPSA July 8, 2011 9

10. MEDICARE BONUS TOTAL POP DESIG TEST THRESHOLDS GEO HPSA Sequential/Tiered Index Continuous Menu Set List Cutoff Threshold REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES GEO HPSA Factor Analysis Expert Opinion 10

11. TIERED MEDICARE BONUS TOTAL POP DESIG TEST THRESHOLDS GEO HPSA Sequential/Tiered A2: Triggered Threshold Continuous Cutoff Threshold A3: Statistical Weighting REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES GEO HPSA Factor Analysis Expert Opinion A1: Continuous Threshold 11

12. TIERED MEDICARE BONUS TOTAL POP DESIG TEST THRESHOLDS HPSA A1, A2, A3 • Initial Thresholds run • 2500:1 (worst 10% pop) Fewer providers then YES • 1300:1 (median pop) More providers then NO • Models differ only in how health status, access, ability to pay are treated for areas with P2P between 1300:1 and 2500:1 REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES GEO HPSA 12

13. TIERED MEDICARE BONUS TOTAL POP DESIG TEST THRESHOLDS HPSA A1 (and A3) • P2P Threshold • 2500:1 (worst 10%). Fewer providers then YES • 1300:1 (median). More providers then NO • Between 1300:1 & 2500:1, consider health status, access, ability to pay • As health status/access/ATP gets worse, you can be designated with more providers • A1 and A3 differ in weighting of health status/access/ATP REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES GEO HPSA 13

14. TIERED MEDICARE BONUS TOTAL POP DESIG TEST THRESHOLDS HPSA A2 • P2P Threshold • 2500:1 (worst 10%). Fewer providers then YES • 1300:1 (median). More providers then NO • Between 1300:1 to 2500:1 P2P, there is a single threshold for adverse health status, access, ability to pay, regardless of actual P2P • Tested worse 25% of pop REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES GEO HPSA 14

15. TIERED MEDICARE BONUS TOTAL POP DESIG TEST THRESHOLDS HPSA A1, A2, A3 • Choices • Vary the P2P thresholds (1300:1, 2500:1) • How to consider health status, access and ability to pay • Weighting • Threshold REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES GEO HPSA 15

16. MEDICARE BONUS TOTAL POP DESIG TEST THRESHOLDS Geographic HPSA Models * Unit of analysis: Counties, Primary Care Service Areas and Selected State RSAs. REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES GEO HPSA July 8, 2011 16

17. MEDICARE BONUS TOTAL POP DESIG TEST THRESHOLDS GEO HPSA Sequential/Tiered Index Continuous Menu Set List Cutoff Threshold REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES GEO HPSA Factor Analysis Expert Opinion 17

18. INDEX MEDICARE BONUS TOTAL POP DESIG TEST THRESHOLDS GEO HPSA Index Menu Set List B1: Barrier Menu Choice REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES GEO HPSA B2: Defined Barrier Measures B3: Expert Judgment 18

19. INDEX MEDICARE BONUS TOTAL POP DESIG TEST THRESHOLDS HPSA B1, B2 • Index model • all variables are considered in combination with others • There is no Pop to Provider ratio that guarantees, nor precludes designation • Areas with many providers but bad health could be designated • Areas with few providers but good health may not be designated • All inputs are combined into a single score for an RSA for designation REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES GEO HPSA 19

20. INDEX MEDICARE BONUS TOTAL POP DESIG TEST THRESHOLDS HPSA B1 • Creating an index • 90% weight to P2P; 10% to other 3 variables • Combine all other non P2P variables using expert judgment weights • Barriers menu: choose 2 variables from list of 6 • Tested designation cutoff worst quartile (of areas) REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES GEO HPSA 20

21. INDEX MEDICARE BONUS TOTAL POP DESIG TEST THRESHOLDS HPSA B2 • Creating an index • 90% weight to P2P; 10% to other 3 variables • Combine all other non P2P variables using expert judgment weights • Barriers menu: choose 1 from risk variables and 1 from direct measures • Tested designation cutoff worst quartile (of areas) REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES GEO HPSA 21

22. INDEX MEDICARE BONUS TOTAL POP DESIG TEST THRESHOLDS HPSA B3 • This model differs from B2 only in the weight assigned to Pop to Provider v. other variables • B3 50%/50% • B2 90%/10% • Tested designation cutoff worst quartile (of areas) REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES GEO HPSA 22

23. INDEX MEDICARE BONUS TOTAL POP DESIG TEST THRESHOLDS HPSA B1, B2, B3 • How to combine variables • Percentage of method assigned to Pop to Provider ratio v. other three aspects REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES GEO HPSA 23

24. MEDICARE BONUS TOTAL POP DESIG TEST THRESHOLDS How to use these results * • To inform our thinking about the models • Pick best model based on our judgment of the best way to determine underserved areas • Models have flexibility and can be tweaked • Use results to guide us to make the big decisions REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES GEO HPSA 24

25. MEDICARE BONUS TOTAL POP DESIG TEST THRESHOLDS Geo HPSA-Key Decisions * • Pop: provider P2P • Threshold (absolute) • Tiered • Continuous • Non P2P factors • How important non P2P (%) • Providers • Included • Weight • Back outs REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES GEO HPSA 25

26. MEDICARE BONUS TOTAL POP DESIG TEST THRESHOLDS GEO HPSA Sequential/Tiered Index Continuous Menu Set List Cutoff Threshold What are the relative weights? What are the P2P thresholds? REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES GEO HPSA Factor Analysis Expert Opinion GEO HPSA GEO HPSA 26

27. MEDICARE BONUS TOTAL POP DESIG TEST THRESHOLDS Next Steps • Brief large group discussion and questions • Split group discussion • Return to large group to present impact testing REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES GEO HPSA 27

28. MEDICARE BONUS TOTAL POP DESIG TEST THRESHOLDS Next Steps • Brief large group discussion and questions • Split group discussion • Return to large group to report out • Make a recommendation REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES GEO HPSA 28

29. MEDICARE BONUS TOTAL POP DESIG TEST THRESHOLDS Goal Reminder Select the most promising model forgeographic HPSA designation to fully test REASONABLE EVIDENCE BASED PERFORMANCE CONSEQUENCES GEO HPSA 29