NPRM-2

Lessons Learned

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NPRM-2 Stated Goals• Methodological Goals:

– Simplicity– Face Validity– Science Based– Minimize Unnecessary Disruption– Acceptable Performance

• Process Goals– Consolidation & Simplification– Proactivity– Automation– Increased State Role

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Comments: Development and Implementation Concerns

• Process/Input– Stakeholder Input– Collaboration with other federal agencies (CMS)– Time/Data needed to review at local level

• Cost/Effort/Implementation– Complexity of applying rule– Data Availability– Phase In / Appeals process

• Impact on existing system– Understanding of impact analysis & issues with inputs– Varying assessments of loss of designations / grantees– Perception of imposed limits on program allocation of resources

(Tier 1, 2)– Meaning of facility designations in terms of eligibility for resources

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Comments: Technical Concerns • Logic/Validity

– Decision to express all components of underservice in the units of a population-to-provider ratio

– Ambiguous denominator in division of Barrier Free rates– Positive high need adjustments awarded to all communities, even

those with the most favorable indicators– Reliance on the same factor for multiple overlapping components– Applying scales built on total population characteristics to designation

of sub-groups with highly correlated demographics– Treating negative/reversible community characteristics, such as poor

health outcomes, in the same way as characteristics such as percent minorities or elderly which are not targets for change.

• Arbitrary/non-scientific factors– Relative weighting of non-physician providers, interns vs. physicians– Use of 3000:1 cutoff as level of underservice– Relative contribution of different factors to final scoring

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Comments: Technical Concerns (cont.)

• Specificity– Geographic – reliance on counties for statistical model

and default service areas– Sub-population designation – stated intent that high

need indicators could be used in place of sub-population methods

• Policy/Judgment Calls– Ob/Gyns, Interns, ‘Mid levels’ in states with limited

scope of practice– Eligible sub populations for designation– Eligible facility types under safety net designation option– RHCs as back-out location for federal providers– SCHIP as safety net provider factor– Combination of HPSA and MUP into a single entitiy

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Potential Lessons Learned• Broad based input is key

– Largely addressed through NRM process• Must be purposeful in both selection of factors and

methods for integrating them• Consider that accommodations for one group may

be considered biased against others• Maintain clear lines between designation and

program resource allocation decisions• Impact testing methods must be clear and

limitations acknowledged• Minimize local technical effort but assure a process

for local involvement• Need clarity on implementation plan and process to

obtain and maintain designations