Recruitment & Financial Benefits of Health Professional Shortage Areas

Recruitment & Financial Benefits of Health Professional Shortage Areas Bobbi Buckner Bentz, MHA, MPH Primary Care Office Director Iowa Department of Public Health

Presentation Goals What is a Health Professional Shortage Area? How are Health Professional Shortage Areas designated? Why should rural practices know if they are in a Health Professional Shortage Area? Financial benefits Recruitment benefits

Health Professional Shortage Area Designations

Health Professional Shortage Areas US Health Resources and Services Administration (HRSA), Office of Shortage Designation, provides guidelines for determining federally qualified health professional shortage areas (HPSAs). State Primary Care Offices analyze and submit requests for shortage designations to HRSA. In Iowa, the Primary Care Office is at the IDPH and Bobbi Buckner Bentz and Lloyd Burnside are the contact individuals (bbuckner@idph.state.ia.us and lburnsid@idph.state.ia.us) Shortage designations indicate geographic areas with a shortage of primary care physicians, psychiatrists, and dental providers for a given population according to the HRSA guidelines.

Types of Shortage Designations Health Professional Shortage Areas (HPSAs) Hip-sah Refers to a shortage of primary care, dental, or mental health professionals in a given geographic area for a specific population. 3 Types of HPSAs: Primary care HPSA, Dental HPSA, Mental Health HPSA Medically Underserved Areas (MUAs) and Medically Underserved Populations (MUPs) Refer to a specific population group in a defined area Governor s HPSA A designated process in which HRSA approves a shortage designation process created by states for the specific purpose of eligibility for Rural Health Clinics. Iowa has a Governor s designation process. Facility HPSA designations Specific to facilities that meet specific ratios of population to provider (example: prisons) Automatic HPSA designations Used for certain types of facilities that may not be physically located in a HPSA (example: Rural Health Clinics) for purposes of eligibility for state and federal loan repayment

HPSA and MUA/P Comparison Designation Types Key Variables Used Providers included Providers excluded Geographic Population Facility HPSA Population-to-provider ratio Primary Care physicians Dentists and dental extenders Psychiatrists FTE of the above in primary care outpatient settings J-1 visa waiver physicians NHSC physicians FTE in admin, teaching, inpatient Geographic Population MUA/MUP Ratio of primary care physicians to 1,000 population Infant Mortality Rate % of population with income below poverty % of population >65 Primary Care physicians FTE of the above in primary care outpatient settings J-1 visa waiver physicians NHSC physicians FTE in admin, teaching, inpatient

HPSA and MUA/P Comparison Service Area Definition Scoring Metric Scoring Variables Renewal Process HPSA Natural service area Defined boundaries by census tract, county, etc HPSA Scores Range from 0 (least shortage) to 25 Population-to-provider ratio % of population below poverty Infant Mortality Rate or Low birth weight rate Travel distance to nearest provider Updates required every four years to be redesignated or dedesignated MUA/MUP Cohesive neighborhoods Defined boundaries by census tract, county, etc Index of Medical Underservice Range from 0 (most underserved) to 62 Primary medical care physicians per 1,000 population % of population below poverty level Infant Mortality Rate % of population >65 No updates required once an MUA/P always an MUA/P!

Primary Care HPSAs Two ways to calculate Primary Care HPSAs Geographic HPSA: Ratio of primary care physician provider FTEs to resident civilian population 3,500 residents to 1 physician FTE = a HPSA If area has high needs, 3,000 to 1 physician FTE = a HPSA Population group HPSAs: Ratio of the population in the service area at or below 200% of poverty level to FTE physicians serving this population. 3,000 residents to 1 physician FTE serving population = a HPSA if 30% of population is also at or below 200% of federal poverty level. Primary Care HPSAs are required to be re-analyzed every 4 years and re-designated if they still qualify. HPSAs are scored to indicate severity of need.

Medically Underserved Areas/Medically Underserved Populations Iowa s Medically Underserved Area and Medically Underserved Population designations are a mixture of whole-county and partial county designations. The PCO submits a request to HRSA to designate an area as an MUA or MUP when the area meets HRSA guidelines by using a specific mathematical formula that scores geographic areas on four criteria: 1) percentage of population below poverty, 2) percentage of population over age 65, 3) infant mortality rate, and 4) primary care physicians per 1,000 population. Receives a score to indicate level of underservice. Once an MUA/MUP always an MUA/MUP.

Mental Health HPSAs Iowa s mental health HPSAs are comprised of groupings of counties referred to as mental health catchment areas HPSA = population-to-psychiatrist ratio greater than 30,000 residents to 1 psychiatrist If the area has high needs, defined by having high poverty OR high youth ratio OR high elderly ratio OR high substance abuse prevalence, then the area may qualify at a 20:000:1 ratio Mental Health Care HPSAs are required to be reanalyzed every 4 years for re-designation or dedesignation

Dental Health HPSAs Iowa s dental health HPSAs are all whole-county HPSAs except for one small HPSA in the Des Moines metropolitan area that is only a portion of Polk County. 3 Methods of Analysis: Geographic HPSA = 5,000 residents to 1 dental provider FTE Population low-income HPSA = 4,000 residents at or below 200% of poverty to 1 dental provider FTE serving this population Population Medicaid-eligible HPSA = 4,000 residents in service area eligible for Medicaid to 1 provider FTE serving this population Dental Health Care HPSAs are required to be re-analyzed every 4 years for re-designation and de-designation.

Shortage Designation Issues HPSAs are required to be re-analyzed every 4 years for re-designation and dedesignation some areas may be receiving a benefit from the HPSA and then have a successful recruitment effort and the HPSA goes away. HPSAs also receive a score from HRSA to indicate the severity of the shortage Iowa generally has low scores and those scores play into the ability to access some state and federal resources. Need cooperation and timely feedback from sites to determine appropriate FTE and number of extenders for accurate HPSA designations. Designations require feedback from 2/3 of all providers in service area. The designation occurs at a snapshot in time, every four years, although FTE is constantly changing. The Affordable Care Act requires HRSA to propose a new methodology for analyzing and designating HPSAs which could mean a whole new ballgame ~Summer 2011.

Benefits of Shortage Designations

Shortage Designation & Programs Federal or State program requiring Shortage Designation Shortage Designation J-1 Visa Waiver Nat l Health Service Corps State Loan Repayment Federally Qualified Health Center Rural Health Clinic Gen Surg Incentive Payment *New* EHR Incentive Payment *New* Medicare Bonus Payment Primary Care HPSA Geographic HPSA Population HPSA Dental Care HPSA Geographic HPSA Population HPSA Mental Health HPSA MUA/MUP Governor s HPSA

HPSA Incentive Payments

HPSA Incentive Payments Medicare Bonus Payments HPSA Bonus Payment Program 10% physician bonus payment on physician charges in a Geographic Primary Care or Mental Health HPSA, paid quarterly. Look up tool by zip code: http://www.cms.hhs.gov/hpsapsaphysicianbonuses/ HPSA Surgical Incentive Payment Program *New* 10% bonus to general surgeons when furnishing a major surgery (10 or 90 day global) between January 1, 2011 and December 31, 2015 in a geographic primary care HPSA, paid quarterly. http://www.cms.gov/mlnmattersarticles/downloads/m M7063.pdf

EHR HPSA Bonus Another reason to get on board with Meaningful Use of Electronic Health Records Recovery Act provided that the amount of the annual EHR incentive payment limit for each payment year be increased by 10% for eligible providers who predominantly furnish more than 50% of services in a geographic primary care HPSA. CMS will use the frequency of services provided over a oneyear period from January 1 to December 31 rather than allowed charges to determine if an EP qualifies for an HPSA bonus. https://www.cms.gov/mlnproducts/downloads/cms_ehr_ti p_sheet.pdf

Additional Primary Care Bonus *NEW* PPACA authorized Incentive Payment Program for Primary Care Services NOT HPSA-specific 1/1/11 12/31/15 Primary Care defined: physician with primary specialty designation of family med, internal med, geriatric med, or peds; or a NP, clinical nurse specialist, or PA for whom primary care services accounted for at least 60% of the allowed charges under the Physician Fee Schedule for the practitioner in a prior period Paid monthly or quarterly in an amount equal to 10% of the payment for such services under Part B. Bonus is provided in addition to the 10% physician HPSA bonus if the provider is in a geographic HPSA. http://www.cms.gov/mlnmattersarticles/downloads/mm7060. pdf

HPSA Recruitment Programs

Provider Types Loan Repayment Programs National Health Service Corps Primary Care Physicians NPs & PAs Certified Nurse Midwives Dentists & Hygienists Psychologists Clinical Social Workers Licensed Prof. Counselors Marriage & Family Therapists Psychiatrists Psychiatric nurse specialists PRIMECARRE Primary Care Physicians NPs & PAs Certified Nurse Midwives Dentists & Hygienists Psychologists Clinical Social Workers Licensed Prof. Counselors Marriage & Family Therapists Psychiatrists Psychiatric nurse specialists Nursing Education Loan Repayment Nurses who have received a diploma, an associate degree, a bachelor s degree, a master s degree, or a doctoral degree in nursing Hours Full & Part-time options Only full-time (32 hrs/wk) Only full-time (32 hrs/wk) Funding Up to $60,000 first two years, then 1 year continuations Up to $60,000 first two years, then reapply in 2-year increments 60% of total qualifying loan balance When to Apply Currently open until May 26 Annually, late summer/early fall, open for about 4-6 weeks Annually, currently open until February 8, 4pm

Loan Repayment Requirements Facility Type or Location Site Application? Provider Application? National Health Service Corps Any outpatient primary care clinic Must be in a HPSA Can be non-profit, public, or for-profit Site must first complete a site application before provider can apply for loan repayment. Accept Medicare, Medicaid, and SCHIP Have a sliding fee scale for low-income uninsured patients Yes takes about 4-6 weeks to process Yes after site approved, 60-90 days to process PRIMECARRE Any outpatient primary care Must be in a HPSA Must be non-profit or public Accept Medicare, Medicaid, and SCHIP Have a sliding fee scale for low-income uninsured patients Web Address: http://nhsc.hrsa.gov/ http://www.idph.state.ia.us/h pcdp/primecarre.asp No. Nursing Education Loan Repayment Dependent on type of facility, qualified facilities include: DSH, CAHs, FQHCs, RHCs, Nursing Homes, Public Health Agencies, Hospice, Home Health Agencies, Skilled Nursing Facilities, Ambulatory Surgical Centers, schools of nursing Does NOT have to be a HPSA Cannot be: free standing clinics that do not qualify as a facility above, renal dialysis centers, private practice offices, assisted living facilities, clinics in prisons, & private for-profit clinics. No. Yes processed in 3-4 weeks Yes recipients notified by September 30. http://www.hrsa.gov/loanscholarships/re payment/nursing/index.html

Type of Professional PRIMECARRE Awards Issued 2008-2010 Number of Individuals Awarded Nurse Practitioners 3 89,672 Nurse Midwife 1 $30,000 Dentists 3 $120,000 Physicians 5 $285,570 Licensed Social Workers 2 $73,845 Mental Health Counselors 2 $59,450 Physician Assistants 4 $130,756 Clinical Psychologists 2 $120,000 Dental Hygienists 2 $59,877 Total 24 $969,170 Total Amount Awarded (Federal and State Funding)

J-1 Visa Conrad 30 Program

Conrad 30/J-1 Visa waiver program IDPH utilizes State Conrad 30 Program to support international medical graduates to practice in Iowa through a visa waiver. Physicians supported under J-1 visa waivers practice in Iowa for a minimum of 3 years. PCO has been using J-1 program since 1996.

Who are J-1 visa physicians? J-1 visa physicians are international medical graduates (IMGs) in the United States on a J-1 visa. The J-1 visa is a visitor program that allows IMGs to remain in the United States while completing residency and fellowship training. At the end of training, the J-1 visa requires IMGs to return to their home countries for a period of two years. The Conrad 30/J-1 visa waiver program waives this two year requirement in exchange for three years of work in the state.

The State of Iowa waiver policy: Iowa J-1 Waiver Program Some requirements are federal immigration requirements, others are state-policies/priorities that can be adjusted as need be. Prioritization of waiver requests based on: Primary care specialty, including psychiatry Rurality of practice site Site status as an FQHC hold slots for FQHCs until March 1 to allow for recruiting Sites must document an inability to recruit for a specific position for a period of at least 6 months. Sites must make an argument for the necessity of the provider including information on patients to be served, unmet need in that specialty, % of patient population with Medicaid, Medicare, or without insurance, etc. Iowa does not use many undesignated slots per year 2-3. Waiver requests accepted on a federal fiscal year basis beginning October 1. Plan to use all 30 slots this year, currently 36 possibilities to review and allocate slots among.

Additional Resources HPSAs and NHSC Site Designation Questions Bobbi Buckner Bentz, Iowa Primary Care Office 515-281-7223, bbuckner@idph.state.ia.us PRIMECARRE Questions Erin Drinnin 515-281-3166, edrinnin@idph.state.ia.us Look up a HPSA: http://hpsafind.hrsa.gov/ Health Care Shortage Designations: HPSA, MUA, and TBD http://www.nhpf.org/library/background-papers/bp75_hpsa- MUA_06-04-2010.pdf