Negotiated rulemaking, Day 3

Day 1 and Day 2. The Negotiated Rulemaking committe has split into two workgroups this morning who are each addressing the same task: how to put together the supply of primary care in an area with the population of a service area. The key question is whether to simply count the population which is now what is done, or whether to adjust the population for need in some way. Possibilities:

• age and gender adjustment
• use of visits to primary care (actual - needed). Of course you have to set the need standard
• need of population that doesn't use actual use of visits

10:25am: in my workgroup, quick consensus that at least an age and gender adjustment based on visit rates is the minimum adjustment. Some interest in doing more complicated and comprehensive adjustments. Merging groups. Our groups bottom line was:

• age and gender adjustment
• with evidence of high need, the threshold for a HPSA designation would be reduced (similar to current policy)

11:05am: The two groups have merged and is there is consensus on the the weighting of the population by age and gender using the use rates from MEPS of persons with good access to care and average health status.

An issue that has been pushed for later is whether/how the HPSA designation approach will have a health status/high need adjustment. Currently there is an adjustment that works as follows: typical population-to-provider ratio ratio for HPSA is 3500:1; in presence of high need, the designation ratio is reduced to 3,000:1. Whether and if yes, how to have such a second step in HPSA.

11:30am: Discussing how to set the threshold for the population-to-provider ratio for HPSA designation. Talking in terms of where to draw the line conceptually, meaning 25th percentile, median, etc. Discussing how the 3500:1 was the 25th percentile in mid-1970s, but 3500:1 written into the rules and not the 25th percentile. Lots of discussion about tradeoff between focusing resources. CMS particularly interested in HPSA because at this point all physicians practicing in a HPSA get a Medicare bonus payment (10% bump of part B)....a large drop in HPSA designation ratio that increased HPSA designations would have automatic impact on Medicare part B. For most other programs, designations are the first step to allowing communities to apply for funding, but doesn't guarantee it will flow to communities.

In the background is a general awareness of the community that the rules the committee writes should try and be flexible in a way that allows for updating as things change over time.

Noon: We set subcommittees to work between now and the next meeting. I had to leave early. This was a productive meeting and we made a good deal of progress on all parts of the MUA and on provider availability which is relevant for both the HPSA and MUA.