Day 2 Negotiated Rulemaking Committee

9:30am: Starting out today with an important discussion of the difference/relationship (if any) between HPSAs and MUAs. Dealing a great deal with the differences between the statutory language and the current rules and operating procedures. Key discussion. Committee had tentative consensus that we will have two processes, HPSA and MUA and that seems to hold still. My understanding of the statutes would make it very hard (impossible) to have one overall designation approach. Further, there are distinct programs that use these designations, some using HPSA and others MUA/P designations.

10:30: Discussion of measures of supply of primary care providers, with report from the data technical subcommittee on these issues. Lots of detailed issues to discuss, who is a primary care provider, who provides primary care, who (what types of providers) to be excluded from determining supply for purposes of designation, data sources to measure same, etc.

10:55: Thought this part would be straightforward, but roadblock on how to/whether to account for the provision of primary care by specialists for the purpose of determining supply of primary care. Sigh.

11:30: Still discussing how to determine primary care provider supply. Issue of how to count non-physician providers a big task (essentially a weighting issue). The technical subcommittee has recommended counting of Nurse Practitioners (NP) and Physician Assistants (PA) in the determination of primary care supply for the purpose of HPSA designation, which is not currently done. The distributional politics of this are tricky. As you expand who is counted, the supply goes up and makes it harder to get a designation, especially in states with more open/advance practice laws for non physician providers. Adding such providers will require a recalibration (meaning you can't keep a ratio to define supply based on one type of provider).

12:30: Lunch break. If my granddaddy were alive, he would say we are on a twisty path....

1:15: Started back and working to clarify some consensus on what types of providers will count as primary care and to clarify what analytical tasks the data/technical subcommittee will complete for the February meeting.

2:30: working now on what population adjustments may need to be made in calculating provider:population supply ratios. For example, what to do about residents in prisons, jails, long term care facilities and the like.

3:10: some discussion on different types of adjustment (age, race, sex).

3:45: We are now working through the pros/cons of several variables that could be used as measures of/proxies for health status that could be used in an index to designate areas as being medically underserved and/or to denote high need for areas seeking a HPSA designation.

4:35: now talking a bit about the merits of having a unified index-type measure (end result, one number) from a disaggregated approach, where you would explicitly show the various parts of an index.

5:15: continuing discussion of an index approach that combines direct measures of health status with social deprivation type measures (area level variables that have been shown to proxy health status/outcomes). One issue being discussed is the poverty rate and how it doesn't adequately account for cost of living. This is important because the research done by some of the data/technical subcommittee shows that poverty level is one of the most important proxies of bad health outcomes/high need. How to take cost of living into account?

We have also talked about the RWJ County Health Rankings and looking at the variables they use and the weights they used. The source data are mostly vital statistics, BRFSS, some Dartmouth Atlas info and other economic measures....they assign county scores but don't observe data in all counties for all variables they use. My take on this is that it is a cousin of where we are likely to end up....there are only so many ways to do this....the key turns out to be how you weight particular items in an index.

5:45: Made progress today.....28 members is a lot to have on a committee. Just sayin.