Concepts for Approaching Population Group Designations

1. Concepts for ApproachingPopulation Group Designations

2. Population Group Discussion Outline • Overall Concept • Current HPSA/MUA approaches • Considerations for designation of Population Groups • Potential Approach • Population Issues • Need for Service Considerations • Provider Capacity Issues • Other Indicators beyond need/supply • Consideration of Potential Population Groups • Social Determinant Populations • Economic Determinant Populations

3. Population Group Designation Concept • GOAL: To provide designation methods to identify and quantify underservice and access issues impacting sub-population groups in an area • Barriers to care are different from those of the general population • Issues might otherwise be masked if access is assessed at the community level • Potential General Approaches: • Define specific eligible population groups • Establish parameters for eligible population groups in general

4. Current Approach Specifications and Methods • “Population Group” HPSA Note: Not eligible for Medicare Incentive Payments (MIP) • Provider Ratio is based on sub-population group count to provider FTE accessible-to/serving that population (FTE/Population) • Ratio is lower for population group designations • 3000:1 vs 3500:1 • Not permitted to use high-need/insufficient-capacity

5. Current Approach Specifications and Methods • Medically Underserved “Population” (MUP) Note: Not eligible for Rural Health Clinic (RHC) • Provider Ratio is based on sub-population group count to provider FTE accessible-to/serving that population (FTE/1000 population) • All other IMU components (% elderly, % poverty, IMR) not affected – assessed based on total population except IMR if available • Threshold for designation not affected

6. Current Approach: Population Groups Currently Designated • Low Income (most prevalent) • Must represent at least 30% of the total population in the area • Medically Indigent • Medicaid eligible • Linguistically Isolated / Non-English speaking • Special Populations (many done as low-income) • Homeless • Migrant/Seasonal • Public Housing • Native American (automatic for HPSA)

7. Population Group Designation Considerations • Applicability of sub-population group to existing programs • Program eligibility is not directly contingent on what population group is designated • Programs could use application requirements to restrict eligibility • Programs could use scope-of-project to restrict use of resources • Priority • Does geographic designation take precedent? • Exclusivity • Can an area have both a geographic and a population group designation? • Can an area have more than one population group designation for separate groups?

8. Potential Approach to Designation Methods for ‘population groups’ can be similar to assessing underservice in the overall population • Supply/Demand • Quantify population • Assess need for primary care services • “Barrier Free” demand • Adjusted for health status • Assess appropriate & willing FTE/visit capacity available • Factors exclusive of Supply/Demand • Disparities in health outcomes • Other indicators of medical underservice • Alternative methods (facility / safety net)

9. Population Group Designation Considerations • Can the group be clearly defined and counted? • What are the defining characteristics? • Data source, geographic units? • Available by age and/or gender or just count? • Is the population stable throughout the year? • Is there a minimum population limit for designation? (Minimum for effective govt. intervention) • Minimum number of individuals • Minimum percent representation in area • Is the group coherent in terms of access issues?

10. Need/Demand for Service Considerations • Any reason not to use Barrier Free rates (with health status adjustment) for estimating need/demand? • Total population rate if age/gender not known • Can health status of group be adjusted for? • MEPS can be used to estimate a ‘blanket’ health status differential for groups that can be observed in the data • Literature or other sources might provide insight into health status disparity for other groups

11. Provider Capacity Considerations • Proportional reductions in total provider capacity tied to nature of barrier(s) faced by population group • Financial, Linguistic, Discrimination, Special skills/ competency/accommodations • Consider prevailing vs. overlapping barriers • Can ‘accessible’ capacity be feasibly measured? • Most factors of interest are not in provider lists • Survey typically required • How likely are providers to know or be willing to respond? • Alternatives for ‘Needle in Haystack’ categories? (ie. homeless) • Visit/Claims based capacity can be used where population ties to known administrative data (ie. Medicaid)

12. Indicators Beyond Supply/Demand • Health “Outcome” Disparities • Are certain unique types of outcomes indicative of primary care access for this group? • Incidence/Prevalence, Morbidity/Mortality, Adverse Utilization • Separate from discussion of indicators for total pop. • Can outcomes for the population group be assessed separately in the available data? • Disparate compared to what? • Overall population locally? • Overall population nationally? • Sub-population group nationally? • Statistical significance of disparity/difference for small populations

13. Indicators Beyond Supply/Demand • Other indicators of primary care underservice? • Ties to overall discussion of other characteristics of underservice and how to assess them if they exist • Other considerations: • Different service area parameters? • Different thresholds? • Ability to conduct impact testing for pop. groups? • Potential for baseline national designation?

14. POTENTIAL POPULATIONS TO CONSIDER • Committee’s Underservice Discussion Identified a Number of Possible Candidates • Populations determined by Social Factors • Populations determined by Economic Factors

15. Social Determinant Populations Identified • Communication/language • Class • Culture • Education/cognitive ability • General literacy • Health literacy • Health status • Diagnosis (i.e. HIV, comorbidity esp. behavioral /mental health issues, other medical complexity) • Disability • High risk occupations • Age (i.e. <18 and >65) • Race/Ethnicity • Health disparities • Health inequity • Bias/discrimination • Sexual orientation • Immigration status • Proof of status/documentation • “fear” of the system • Post corrections status • Post military service status • Housing status/setting • Social isolation • Patient satisfaction • Religion

16. Economic Determinant Populations Identified • Insurance status • Ability to pay - independent of IS • Public insurance (esp. low Medicaid reimbursement) • Class

17. Population Group Designations-Decision Points • How to identify and quantify Pop. Groups • How to measure need/demand • How to measure capacity/supply • Indicators beyond supply/demand • Data Availability across the board • Constraints? • Types of groups to be considered • Minimum size • Availability of program interventions