HRSA Neg Reg Day 3

Day 1 and Day 2.

Big Picture: The health professional shortage area (HPSA) and medically underserved area (MUA) methodology have been used by the federal government to classify areas as eligible for special resources such as National Health Service Corps providers, Community Health Centers, and insurance bonuses such as the 10% Medicare Part B bonus for physicians in HPSAs. There have been two failed attempts (late 90s by Clinton Administration; 2008 by Bush administration) to update these methods, which have been in use in a similar manner since the 1970s. The Affordable Care Act created this committee to develop a rule that would then be put forth by the Sec. of HHS as a proposed final rule that will then be open for comment from the public and interest groups. The point of having a negotiated rulemaking committee is to get the stakeholders that shot down the two previous attempts at developing a new rule involved in making the rule.

8:00am: Work groups are meeting for an hour, to reconvene the full committee at 9:00am. Key issue will be whether the Facility designation work group will be able to bring forth a proposal for the full committee.

9:15: having a report on rational service areas. For both geographic MUA and HPSA designations you have to pick a rational service area for medical services to then seek a designation. Bottom line for all of the various geographical units that could be used for rational service areas is that it is easier to identify the problems with any approach than it is to come up with something that is better. Key issues:

• what data are available at a given geography?
• there is a mixture of statutory requirements for rational service areas and flexibility that this group has
  
• what is the burden implied on local areas if primary data will be used? Throughout our work we have reproduced the following conversation in many contexts: (1) lets give local areas more flexibility in seeking designations; (2) the more flexibility we give them, the more work that it implies for them.
  
• is there any geographical conception of a RSA that makes sense for the entire nation? (probably not)
• Absolute distance and geographical barriers (mountains, rivers without bridges) are important in rural areas, and traffic and lack of public transportation are key in urban areas. Travel time can be a particular problem in both urban and rural areas
  
• Impact testing of the new rule will be key....but such testing will be limited by available data and geography units and/or whatever states can do quickly (for example, if they have legally defined rational service areas as 6 or 7 states have).
  
• How do you make the new proposed rule more flexible, meaning able to use new data methods and sources, especially in the area of potential future innovations in relating data to geography

The presentation on rational service areas has set the key decision as needing to pick a basic geographical unit of analysis, from which you would aggregate small units to create a rational service area:

• Census tracts
• ZIP codes

Again, much easier to criticize either than it is to provide a better approach.

10:00am: continuing discussion of rational service area. Some movement toward not picking a given geography for rational service areas in the actual rule but perhaps only picking one for impact testing. Others want impact testing of the possible geographies.

10:30am: wrapped up rational service area discussion. Will do preliminary testing of draft recommendations with both census tract, ZIP based and county based RSAs. Created a work group to give more attention to rational service areas between now and next meeting. Seemed to be movement among the group away from the idea that we must pick a basic geographical building block approach to define rational service areas, and to allow areas to use different regimes.

10: 40am: receiving a report from the facilities work group. This seemed non controversial to me initially, but the group seems hung up. Issues as to yet unclear to me.

11:25am: we had a 1 hour discussion around the facility designation issue. We did not reach a consensus and will create a new work group to deal with these issues. The main sticking point seems to have been the proposal to create a HPSA Facility designation subcategory of a 'magnet' or 'center of excellence' to deal with particular vulnerable populations such as those infected with HIV, LGBT, developmental disabilities, etc. The issues seemed to be:

• making clear this was a 'last chance' designation....meaning only available if no other types of designations applied
• whether to have a income test or not; issue goes to broadening definition of underservice to those with relatively high means but who still cannot get reasonable care
• it got tied up with discussion of prisons, which are now being discussed separately
• what types of organizations could apply for such a designation
• some extra level of heat amongst some committee members that I didn't ever get

11:35am: Now discussing HPSA facility prison designations. Discussion of difference between prison and county jails. Committee needs a group hug....

11:50am: talking about impact testing of draft alternatives. What will be used to assess how well the new methods are identifying medically underserved areas and health professional shortage areas.

12:20pm: lunch. I may not be blogging in the afternoon as I am making an early getaway to get home for a kid's school event.