concepts for assessing primary care provider capacity
TRANSCRIPT
Concepts for Assessing Primary Care Provider Capacity
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Question:How much primary care capacity is
effectively available to a given population?
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Assessing Primary Care Supply/Capacity
• Goal: Quantify the actual level of primary care provider capacity available to a population.
– Methods should correspond to the parameters used for estimating population-level need/demand for primary care
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Quantify Need/Demand(Visits for Benchmark, Age Gender Adjusted,Average Health Status)
Adjust for PopulationHealth Status
(Increase if below avg. healthstatus, decrease if above )
Quantify Supply(Visit capacity for appropriate
primary care providers )
Scale(s) of ProviderAdequacy/Shortage(Combined measure of
Supply vs Demand )
Set Threshold(s) forHPSA Designation
Assess Health Outcome Deficits/Disparities(Areas/Populations with
persistently and significantlynegative health indicators )
Assess Other Indicatorsof Med.Underservice
(Nature/Indicators TBD)
Scale(s) of MedicalUnderservice
(Assessed separately or Integrated into an index)
Set Threshold(s) forMUA/P Designation
or
or
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Overview of Capacity
• Current HPSA/MUA approaches to capacity• Potential approaches to measuring capacity
going forward• Key Decision Points
– Types of providers to include– Methods for counting of provider FTE– Exclusion factors for providers– Translating FTEs into Visits– Other factors influencing access to providers– Claims/Visit based approach
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Current Designation Approach to Provider Capacity
• Same for MUP and HPSA– Primary Care Physicians Only:
• Specialties: FP, GP, IM, PED, OB/G• Excludes NHSC obligated, J-1, and federally employed
providers• Excludes administration roles, inpatient/emergency,
locum tenens, suspended license• Interns and residents counted as 0.1 FTE
– 40 hour/week patient care basis for FTE, 1.0 FTE max
• Includes office, rounds, consults, lab & x-ray review• Location specific
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Current Designation Approach to Provider Capacity- Accessibility Considerations
• Low income FTE = % service to Medicaid and sliding fee
• Medicaid & SFS based on survey of % of patients/practice
• Medicaid Method’ – 5,000 claims = 1 FTE
• Other information:• Language/Interpretation• High need (closed practice, wait times for
new/established patient)• Service to special populations
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Current Approach to Provider Capacity (cont.)
• On-line Designation Application System (ASAPs)– Populated with AMA data if no state data uploaded– State Data if available; usually licensure
• Other Sources for provider lists:– Association lists– Hospital admitting lists– Medicaid/Medicare lists– Yellow pages
• Survey of providers typically conducted• Claims from state Medicaid departments
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Potential approaches:
A. Estimate capacity based on individual provider characteristics
B. Claims/Visits based assessment of capacity
C. Other?
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A. Estimating Capacity Based On Individual Provider Characteristics
• Starts with a list of potential primary care providers– Potential sources as noted in current methods
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A. Considerations for AssessingIndividual Provider Capacity
• Provider types/specialties to include
• FTE basis
• Exclusions
• Relative capacity
• Other access related characteristics
• Provider Data Issues and alternative sources
• Provider Back-out options
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Provider Type Definition
• Physician Specialties to Include as PCPs?– General Practice, Family Practice, Internal
Medicine, Pediatrics, Obstetrics/Gynecology? • Interns/Residents?• Board Certified vs. Board Eligible?
– Sub-Specialties within broader groups?• Presence of a secondary specialty beyond primary
care (i.e. IM + Cardiology)• Geriatrics, Adolescent Medicine, etc.• Obstetrics or Gynecology Only
– Hospitalists?– General Surgeons?
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Provider Type Definition• Additional Providers
– Nurse Practitioners, Physician Assistants, Midwives?
• Certification type– PA vs PA-C – CNM vs CPM
• Specialty (similar but not same as physicians)
• State specific variants: Scope of Practice – MD oversight, prescriptive authority, referral/diagnosis
• Others?• Community Health Aides and Practitioners?• Alternative/ Holistic/Naturopathic medicine?
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Full Time Equivalent (FTE) CalculationConsiderations
• Uniform Hourly Basis for Full Time– 32,36,40 Hours?– Point in time vs. time period?
• Potential inclusions/exclusions– Rounds, Admitting/Discharging, Consults?
• Hospitalist available, Admitting privileges
– Clinical documentation, QA, Consults, etc.?– Time spent ‘On-Call’?– Self assessed percentage primary care?– Hours paid vs. hours worked
• Vacation, CME?• Maternity/Short Term disability leave?
• Location Specific (multiple practice locations)
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Potential Provider Capacity Exclusions• Work Setting
– Hospital Only, Gov./Military/VA facility, Corporate?– Urgent Care Centers? Retail clinics?– Institutional Providers (LTC, Prison, Schools)?
• Separate issue for facility designationsNOTE – Federally-linked provider issue to be discussed separately
• Professional Activity– Practice Administration, Legal, Clinical Teaching, Research,
Advocacy/Prof. Society, Other non-patient care?– Locum Tenens?
• Status– Retired, Disabled, Suspended or Restricted License, Temporary
leave, etc.? – Age Adjustment / Aged out?
• Foreign Medical Graduates?– ‘Consideration’ is a legislative requirement
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Other Attributes/Indicators of Capacity
• New Patients Accepted?– Overall vs. sub-population groups– Individual vs. practice– Restricted access (eg. closed panel managed care)
• Wait times?– Routine appointments – New vs. established patients– Wait time in office
• Turnover/Stability?• Citizenship/Visa Status?
Need to consider how to factor into capacity
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Options Regarding Counting of Designation Related Resources
• Goal: Recognize role of designations and related federal programs in supporting capacity – Full inclusion of capacity related to designations/
programs (could lead to undesirable ‘yo-yo’ effect)– Full exclusion of related capacity (could lead to false
measure of actual access and potential over-allocation of resources)
• Considerations:– Full, partial, or no back-out– Eligible programs/providers (see next slide)– Separate tracking of back-out FTE by program– Different exclusions for each designation category
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Designation/Program Linked Resources Considerations for Excluding Capacity
• Designation Dependent (for provider placement)– National Health Service Corps– State Loan Repayment Program– J-1 / Conrad 30 / ARC Visa Waivers
• Designation Associated Locations– Federally Qualified Health Centers/CHCs – FQHC Look-Alikes– Rural Health Clinics– Medicare Incentive Payment
• Other Providers (no current designation linkage)– H1b Visa Waivers– Federally Employed– Tribal Contract/Compacts– Indian Health Service– Other Safety Net providers (free clinics, county health depts., etc.)
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Capacity for Sub-Populations• Goal: To assess effective capacity available to
sub-population groups • Disparate access to care vs. the community overall• Nature of eligible sub-population groups discussed separately
• Current Population Groups Designated – Low Income / Medically Indigent
• Currently % Medicaid and Sliding Fee Scale in practice• Other considerations: SCHIP, state/local/federally subsidized
insurance plans– Medicaid enrolled/eligible
• Currently % Medicaid in practice or Claims data– Linguistically Isolated / Non-English speaking
• Currently % providers/staff offering interpretation or linguistically appropriate care
– Special Populations• Homeless• Migrant/Seasonal
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OPTION: Translating FTE into Visits?• Value of visit-based capacity
– Equates relative capacity of different providers– Equates FTE capacity to visit-based demand
• Use of productivity statistics (visits/FTE)– Average (Mean)– Median or other percentile (25th, 75th, etc.)
• Sources of productivity statistics– UDS (non-profit, underserved populations)– MGMA (private practices)
• Specificity– by specialty or by degree/profession
• Other Variants (frontier, special populations)
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UDS/MGMA Productivity Comparison
(n)Mean
Productivity (n)Mean
ProductivityFamily Physicians * 4,260 3,768 540 3853 102%General Practitioners 381 3,915 N/AInternists 1,545 3,670 2103 3533 96%Obstetrician/Gynecologists 864 3,535 957 2917 83%Pediatricians 1,764 3,952 1596 4633 117%Other Specialty Physicians 310 3,191 N/A
Total Physicians 9,125 3,752 N/ANurse Practitioners** 3,389 2,865 487 2546 89%Physician Assistants** 1,881 3,162 482 2932 93%Certified Nurse Midwives 489 2,496 75 1401 56%
Total Mid-Levels 5,758 2,931 N/A
* with OB in MGMA** also available by specialty in MGMA
N/A
Not Reported
MGMA / UDS Prod. RatioBased on 2009 data
UDS MGMA
N/AN/A
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Primary Care Provider Data Issues
• No data set is complete– Unclear if providers may be missing from lists– Missing/partial data for elements that do exist– Detailed data questions not routinely available
• Hours worked• Multiple practice locations & apportionment• Percent service to sub-population groups• Closed practice, wait times, translation , etc.
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Data on Primary Care Providers
• FT/PT = Full Time/Part Time
• P= Partial• Z= Zip Code• RT = Retired• Date File
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Source AMA w/CMS ACNM AANP AANP AAPA
Year 2007 2006 2009 2010 2010 2010
Unduplicated Provider Identifier Physical Address
Address Type Identifier (Practice/Home/Mailing) One Practice Location Address ? P
Multiple Practice Location Addresses Z Percent allocation at each practice location Z hours
Hours or Percent time worked (Primary Care) FT/PT Overall Work Setting (Office, Hospital, LTC, etc)
Federal or Military Employment Date of Birth/Age Year Year
Practice Status (Active, Retired, etc.) RT Major Professional Activity (Clinical, teaching,
research, admin, etc.)
Primary Speciality N/A Secondary Specialty N/A
Board Certified
Content
Dataset
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B. Estimating Capacity Based On Claim/Visit Records
• Starts with a database of insurance claims or other record of service– Individual provider capacity not necessary
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B. Claim/Visit-Based Capacity Analysis
• Goal: To define current capacity based on a count of primary care service visits from administrative data
• Potentially valuable alternative where:– All services of interest result in claims submitted to a
central repository– Population covered by potential claims can be identified
and counted– Primary care services/providers can be identified in the
claims records– Claims can be attributed to a provider of known location
and/or a point of service
• General approach described/validated in literature – Shah, B. 2007 – HSR; Withy, K. 2010 Ethnicity & Disease
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Potential Applicability of Claims-Based Capacity
• Potential Claim/Visit Based Data Sources– Medicaid (State level or CMS MAX files in 2011)– Medicare – All Payor claims databases (state level)– Evolving Health Information Exchanges
• Process– Define minimum criteria for useable data sets– Define specification for identifying/counting unique
primary care encounters– Determine geographic aggregation to locate capacity– Determine ability to count/locate the related population– Claim/visit counts can be directly compared to
population-based need defined based on visits
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Notes regarding Medicaid Analytic Extract (MAX)
• Derived from the CMS Medicaid Statistical Information System (MSIS)– Consists of Person Summary File & Claims Files– Access to files restricted to government and research
• New claim elements added in 2009 (available in Fall 2011) – Provider Taxonomy – National Provider Identifier (NPI)– Equivalent data available at the state level
• Provides potential national ability to identify:– Medicaid claims associated with each provider
• Place of Service codes can identify federal programs– Medicaid eligible population (zip code level, age groups)– Could provide method for baseline testing of Medicaid/
low-income designations nationally
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Applicability to Measuring Shortage
• Visit-based supply of actual primary care capacity can be compared to visit based ‘ideal’ demand for care by the population– Ratio / percentage– Visit gap / deficit
• Designation linked providers can be identified as attribute of designations for programmatic use and/or back-out
• Other attributes might be factored in – Closed practices, high turnover, etc.