goal: select the most promising model for geographic hpsa designation to fully test july 20, 2011 1

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


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


July 8, 2011

Unit of analysis: Counties, Primary Care Service Areas and Selected State RSAs.

GEOHPSA


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




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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




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




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




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




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




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



July 8, 2011

Unit of analysis: Counties, Primary Care Service Areas and Selected State RSAs.

GEOHPSA




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GEO HPSA


Menu Set List

Expert Opinion

Factor Analysis

Cutoff Threshold

Continuous

GEOHPSA




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GEO HPSA

Index

Menu Set List

B1: Barrier Menu Choice

B2: Defined Barrier MeasuresB3: Expert Judgment

GEOHPSA




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




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




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




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




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




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




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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




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GEO HPSA


Menu Set List

Expert Opinion

Factor Analysis

Cutoff Threshold

Continuous

What are the P2P

thresholds?

What are the relative

weights?

GEOHPSAGEO

HPSAGEOHPSA




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Next Steps

• Brief large group discussion and questions• Split group discussion• Return to large group to present impact

testing

GEOHPSA




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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




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Goal Reminder

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

GEOHPSA




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goal: select the most promising model for geographic hpsa designation to fully test july 20, 2011 1

Documents

hpsa a1

hpsa a2 p2p threshold

nrmc meeting geo hpsa

geographic hpsa models

geographic hpsa designation

a3 p2p threshold

providers a1

model a1