goal: select the most promising model for geographic hpsa designation to fully test july 20, 2011 1
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Goal: Select the most promising model for geographic HPSA designation to fully test
July 20, 2011
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The opportunity to directthis process is now.
The time for big decisions has come.
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July 2011 NRMC Meeting
GEOHPSA 4
Other Ways to Designate
GEOHPSA 5
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
GEOHPSA 6
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
GEOHPSA
REASONABLEEVIDENCE BASED
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
GEOHPSA
REASONABLEEVIDENCE BASED
PERFORMANCECONSEQUENCES8
Geographic HPSA Models *Model A1: Tiered P2P, Continuous Threshold
Model A2: Tiered P2P, Threshold Trigger
Model A3:Tiered P2P, Factor Analysis
Model B1:Index withBarrier Measure Choice
Model B2:Index withDefined Barrier Measures
Model B3:Index withExpert Judgment
Weighting Expert Opinion
Expert Opinion
Statistical Weighting
Expert Opinion
Expert,Alt. on Barriers
Expert,Alt. on Barriers
July 8, 2011
Unit of analysis: Counties, Primary Care Service Areas and Selected State RSAs.
GEOHPSA
REASONABLEEVIDENCE BASED
PERFORMANCECONSEQUENCES
MEDICARE BONUSTOTAL POP DESIGTEST THRESHOLDS
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GEO HPSA
Sequential/Tiered Index
Menu Set List
Expert Opinion
Factor Analysis
Cutoff Threshold
Continuous
GEOHPSA
REASONABLEEVIDENCE BASED
PERFORMANCECONSEQUENCES
MEDICARE BONUSTOTAL POP DESIGTEST THRESHOLDS
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GEO HPSA
Sequential/Tiered
Expert Opinion
Factor Analysis
Cutoff Threshold
Continuous
A2: Triggered Threshold
A1: Continuous Threshold
A3: Statistical Weighting
GEOHPSA
REASONABLEEVIDENCE BASED
PERFORMANCECONSEQUENCES
MEDICARE BONUSTOTAL POP DESIGTEST THRESHOLDS
TIERED
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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
GEOHPSA
REASONABLEEVIDENCE BASED
PERFORMANCECONSEQUENCES
MEDICARE BONUSTOTAL POP DESIGTEST THRESHOLDS
TIERED
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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
GEOHPSA
REASONABLEEVIDENCE BASED
PERFORMANCECONSEQUENCES
MEDICARE BONUSTOTAL POP DESIGTEST THRESHOLDS
TIERED
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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
GEOHPSA
REASONABLEEVIDENCE BASED
PERFORMANCECONSEQUENCES
MEDICARE BONUSTOTAL POP DESIGTEST THRESHOLDS
TIERED
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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
GEOHPSA
REASONABLEEVIDENCE BASED
PERFORMANCECONSEQUENCES
MEDICARE BONUSTOTAL POP DESIGTEST THRESHOLDS
TIERED
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Geographic HPSA Models *Model A1: Tiered P2P, Continuous Threshold
Model A2: Tiered P2P, Threshold Trigger
Model A3:Tiered P2P, Factor Analysis
Model B1:Index withBarrier Measure Choice
Model B2:Index withDefined Barrier Measures
Model B3:Index withExpert Judgment
Weighting Expert Opinion
Expert Opinion
Statistical Weighting
Expert Opinion
Expert,Alt. on Barriers
Expert,Alt. on Barriers
July 8, 2011
Unit of analysis: Counties, Primary Care Service Areas and Selected State RSAs.
GEOHPSA
REASONABLEEVIDENCE BASED
PERFORMANCECONSEQUENCES
MEDICARE BONUSTOTAL POP DESIGTEST THRESHOLDS
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GEO HPSA
Sequential/Tiered Index
Menu Set List
Expert Opinion
Factor Analysis
Cutoff Threshold
Continuous
GEOHPSA
REASONABLEEVIDENCE BASED
PERFORMANCECONSEQUENCES
MEDICARE BONUSTOTAL POP DESIGTEST THRESHOLDS
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GEO HPSA
Index
Menu Set List
B1: Barrier Menu Choice
B2: Defined Barrier MeasuresB3: Expert Judgment
GEOHPSA
REASONABLEEVIDENCE BASED
PERFORMANCECONSEQUENCES
MEDICARE BONUSTOTAL POP DESIGTEST THRESHOLDS
INDEX
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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 GEO
HPSA
REASONABLEEVIDENCE BASED
PERFORMANCECONSEQUENCES
MEDICARE BONUSTOTAL POP DESIGTEST THRESHOLDS
INDEX
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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)GEOHPSA
REASONABLEEVIDENCE BASED
PERFORMANCECONSEQUENCES
MEDICARE BONUSTOTAL POP DESIGTEST THRESHOLDS
INDEX
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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)GEOHPSA
REASONABLEEVIDENCE BASED
PERFORMANCECONSEQUENCES
MEDICARE BONUSTOTAL POP DESIGTEST THRESHOLDS
INDEX
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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)
GEOHPSA
REASONABLEEVIDENCE BASED
PERFORMANCECONSEQUENCES
MEDICARE BONUSTOTAL POP DESIGTEST THRESHOLDS
INDEX
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HPSA B1, B2, B3
• How to combine variables • Percentage of method assigned to Pop to
Provider ratio v. other three aspects
GEOHPSA
REASONABLEEVIDENCE BASED
PERFORMANCECONSEQUENCES
MEDICARE BONUSTOTAL POP DESIGTEST THRESHOLDS
INDEX
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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
GEOHPSA
REASONABLEEVIDENCE BASED
PERFORMANCECONSEQUENCES
MEDICARE BONUSTOTAL POP DESIGTEST THRESHOLDS
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Geo HPSA-Key Decisions *
• Pop: provider P2P– Threshold (absolute)– Tiered– Continuous
• Non P2P factors– How important non P2P (%)
• Providers– Included– Weight– Back outs
GEOHPSA
REASONABLEEVIDENCE BASED
PERFORMANCECONSEQUENCES
MEDICARE BONUSTOTAL POP DESIGTEST THRESHOLDS
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GEO HPSA
Sequential/Tiered Index
Menu Set List
Expert Opinion
Factor Analysis
Cutoff Threshold
Continuous
What are the P2P
thresholds?
What are the relative
weights?
GEOHPSAGEO
HPSAGEOHPSA
REASONABLEEVIDENCE BASED
PERFORMANCECONSEQUENCES
MEDICARE BONUSTOTAL POP DESIGTEST THRESHOLDS
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Next Steps
• Brief large group discussion and questions• Split group discussion• Return to large group to present impact
testing
GEOHPSA
REASONABLEEVIDENCE BASED
PERFORMANCECONSEQUENCES
MEDICARE BONUSTOTAL POP DESIGTEST THRESHOLDS
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Next Steps
• Brief large group discussion and questions• Split group discussion• Return to large group to report out• Make a recommendation
GEOHPSA
REASONABLEEVIDENCE BASED
PERFORMANCECONSEQUENCES
MEDICARE BONUSTOTAL POP DESIGTEST THRESHOLDS
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Goal Reminder
Select the most promising model for geographic HPSA designation to fully test
GEOHPSA
REASONABLEEVIDENCE BASED
PERFORMANCECONSEQUENCES
MEDICARE BONUSTOTAL POP DESIGTEST THRESHOLDS
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