Tuesday, January 18, 2011

Negotiated Rulemaking Committee

The first morning of our fourth meeting got off to a good start with an excellent presentation by the subcommittee that is focusing on issues related to sub-population designations. Key issues of discussion:
  • making space for sub-populations that may emerge in the future which are today unknown; for example, HIV didn't exist (or at least wasn't identified) when these designation approaches were first developed in the 1970s.
  • the relationship between medically underserved population designations and facility Health Professional Shortage Area designations, notably a medically underserved population should result in automatic facility HPSA designations;
  • determining what data sources and what measurement and documentation standards are needed for the designation of sub-populations as being medically underserved (ex. homeless persons)
Good start to the day.

After lunch, the data/technical subcommittee presented our work. We made some good progress in developing some preliminary decisions about types of providers to count for the purpose of HPSA designations. When looking at medically underserved area (MUA) designations, we are looking at different approaches. The main issues/debates are:
  • Do we attempt to directly measure health status/outcome/underservice or use a proxy approach? The tradeoffs are that direct assessment conducted locally would be the most specific, and could be address local realities, but this would be time consuming and the most underserved areas might not be able to launch such research-driven exercises. Basically, there is a tradeoff between specificity and simplicity/ease of designation. Also, a combined approach can be used with proxy measures and direct health measures.
  • Do we put multiple variables/parts of a designation into one index (in which case the weighting of component factors is key), or use disaggregated component measures that identify different 'parts' of the problem?
  • Do we assess these concepts as compared to a normative standard, or do we set designation in a relative sense (e.g., worse quartile)?
Update 4:05pm: now discussing rational service areas, or the geography at which we assess geographical HPSA/MUA. [special population designations will also exist]. The phrase 'Gaussian kernel density' was just used and this has prompted a move toward a coffee break....

Actually, no coffee break but a presentation by David Goodman of Dartmouth, a member of the committee on Primary Care Service Areas (PCSA). County and some sub county unit of geography will be needed for impact of testing of any new method(s) that the committee will propose. PCSA is one option that is national, and can be overlaid with multiple data sources to allow us to understand how new approaches will impact designation.


  1. PCSAs would be a good place to start, but they, in turn, start with the "kernel" of the doctor or doctors. That will tend to diminish the identification of underservice as any undefined but underserved areas will be cut up by competing PCSAs. The geographic underservice will be "allocated" to the PCSAs that touch on or overlay the area with less than enough access. It might be a useful exercise to restrain the geographic dimensions of the PCSAs to see if any or how many areas emerge that have no center of physician activity. This would be a sort of "location-allocation" analysis to identify places with very low access. The remaining areas could be tested for low access with ratios and indices. Just a thought.

  2. A huge issue will also be the incorporation of non-physician primary care providers (whether, if yes, how/what weight). I don't see how they cannot be included given how important NPs especially are to primary care provision. It may be that you need to account for docs and non docs separately....it could be a problem to have one but not the other in an area. Good thoughts about PCSAs. Also, we have been talking about the states that have state specific mandated health care service areas.