May 23, 2008

Health Resources and Services Administration

Department of Health and Human Services

Attention: Ms. Andy Jordan

8C-26 Parklawn Building

5600 Fishers Lane

Rockville, MD 20857

RE: Notice of Proposed Rulemaking -- Designation of Medically
Underserved Populations and Health Professional Shortage Areas -- RIN
0906-AA44, 73 Federal Register 11232 et. Seq. (February 29, 2008),
RIN0906-AA44 (April 21, 2006)

Dear Ms. Jordan,

Oregon appreciates the HRSA effort to develop and adopt a new
methodology to determine designations of Health Professional Shortage
Areas (HPSAs) and Medically Underserved Areas/Populations (MUA/Ps). We
also understand federal statutory constraints that require that both
types of designations remain. We note that the development of a
simplified approach that is more scientifically based is a desirable
goal.

We also appreciate the clarification made in the amendment to the
federal register that extended the comment period 30 days and provided
the clarification that each of the designation types remains eligible
for new funds and NHSC. We believe the shift from "tiers" to "methods"
is more consistent with the original intent of the Primary Care Offices
who provided some of the conceptual framework nearly 10 years ago. The
various methods now provide a more logical set of alternatives for
communities to consider.

The original proposal was developed a number of years ago and, while it
attempts to simplify methods, the Federal Register explanation has been
confusing and incomplete. Given the degree to which states, communities,
and many organizations use designations, it is important that a good
understanding of the proposed changes is shared broadly. In addition, it
is unclear how the many comments HRSA has received will cause it to
adjust the methodology. Therefore, while the 30 day extension is
appreciated and has allowed some time for analysis, we believe it to be
insufficient for the kind of analysis a change of this order requires.

We recommend that HRSA review comments to date, determine what changes
need to be made based on comments then publish an interim document with
more cohesive consistent language and provide an additional opportunity
of at least 60 days for final comment. This is reasonable considering
the length of time the methodology has been under development within
HRSA. We believe the benefit of taking this step will mean much greater
agreement nationwide on the intent, the methodology, and the impact.

In addition to this request, we offer a number of suggestions and
concerns. Please let us know if you have questions based on the items we
note below.

Thank you for your consideration of our recommendations.

1.  We recommend that, consistent with the recent Federal Register
    changes, "method" language be used instead of "tier" language.

2.  **Review Cycles:\
    **\
    HRSA and CMS designation review and update cycles should be aligned
    on a four year cycle. The current unaligned policies make it
    difficult for providers and for primary care offices. It is really a
    four year work load.\
    \
    We assume that, for the first year, only the HPSAs due for an update
    in that year are run by SDB, not all HPSAs as stated in the Federal
    Register.\
    \
    We recommend prioritizing MUAs by age and via agreement with each
    state. **It would be best for areas with both an MUA/P and a HPSA to
    be updated on the natural HPSA cycle. This would avoid an uneven
    work load and duplication. We then suggest updating MUA/Ps with no
    HPSA, over the three years.**

3.  Some implications of the Safety Net Facility Designation are not
    clear -- especially as they relate to rural health clinics and
    eligibility for CMS bonus payments. The Federal Register is largely
    framed through a community health center lens. In general we would
    like to see greater emphasis and clarity in regard to the rural
    health clinics as well.

4.  The Safety Net Facility Designation criteria are problematic for
    rural health and school based health clinics. They require the
    clinic to be open full time. In some isolated rural areas and school
    based clinics this is not feasible and the policy would be
    detrimental to access.

5.  In order to avoid the yo-yo effect for Rural Health Clinics, we
    advise removal of RHC providers similar to the adjustment for other
    federal resources (certified by CMS and reimbursed at enhanced
    rates).

6.  Oregon recommends that the Safety Net Facility method allow for
    inclusion of for-profit private practices which meet the service
    requirements.

7.  Oregon recommends that the medical resident FTE adjustment be
    eliminated because of data limitations due to their transient status
    and uneven impact across states.

8.  Oregon encourages a standard .5 mid-level FTE adjustment regardless
    of state scope of practice rather that the proposed .5 to .8 range
    or make it more clear that states have the option to decide.

9.  The 3000:1 population to primary care ratio, considered by many to
    be too high in the previous iteration of a new methodology in 1999,
    is still cause for concern. We recommend a ratio of 2200:1 as more
    reasonable.

10. Rational service areas "are assumed to be 40 minutes for a frontier
    area and 30 minutes for all other areas unless the provisions of
    paragraph (g)...are invoked by a State." 30 minutes is problematic
    in urban areas. Perhaps states need the option to develop rational
    service area plans for urban areas in addition to HRSA options for
    statewide and rural plans. We believe it is very important that
    states retain the option to make decisions in regard to RSAs.

11. Rules should not be set up so that Method 2 Geographic competes with
    Method 1 Population designations as would happen if a Medicare bonus
    was offered under Method 2 Geographic.

12. Safety Net Facility Designations should meet both the total
    low-income criteria AND the "indigent uninsured" criteria.
    Under-insured patients should be considered in the total percent,
    but not via the indigent uninsured criteria, which are pretty
    minimal.

13. We request that the clarification provided by HRSA, that special
    population and simplified designations are also HPSAs and MUAs, be
    explicitly stated in the new rules.

14. Federal analysis did not take into consideration contiguous area
    analysis. This issue has given Oregon problems in the past and could
    be more problematic than the HRSA analysis suggests.

15. There is uneven application of the contiguous service area rule.
    States with a plan do not have to do any contiguous area analysis
    and states with individual Rational Service Areas do. This is an
    unequal definition of need.

16. A process for dealing with areas where there are no providers needs
    to be developed. (PCO involvement recommended.)

17. A scoring process is needed for all the new designations. (PCO
    involvement recommended.) See scoring section below...

18. All references to the RCP (resident civilian population) should be
    dropped. It skews age and gender application.

19. Oregon recommends that the number of providers not be taken into
    account for areas with fewer than 1000 people.

20. An appeal process is needed to sort out disagreements.

21. The effective population or the total population should be used,
    which ever is greater. We believe it was an unintended consequence
    that the effective rate is sometimes lower than the total
    population.

22. No mention is made of a minimum response rate, nor policy to apply
    FTE to non-responders.

23. The original band of 16 intended for there to be a menu of variables
    to choose form. The rules create 8 fixed variables. This has the
    result of diluting the contribution of any one variable, making it
    possible for pockets of high need to become less apparent. Oregon
    suggests a state should be able to choose 7 out of 8 variables. Some
    choice currently exists between LBW and IMR. Adjustments may need to
    be made in the final score as a result of this change in the number
    of variables.

24. Rules should make clear that survey data can be applied to the
    mid-level FTE. This reduces the chance of a mid-level working at
    multiple sites being over counted.

25. Urgent requests should be limited to come from the state entity
    responsible for designations only.

26. Precision and Clarity of Data:

    a.  Because state data may be so critical to certain designations,
        it is important to know how flexible the federal automated
        system will be to allow for unique state data.

    b.  It will be important for states to know how often federal data
        will be updated.

    c.  It is important now and in the future for HHS to clearly
        describe the data sets, assumptions, and definitions employed
        for each variable.

    d.  Any change in variables should require a [public
        process]{.underline}.

    e.  Data for analysis is different than published data -- also
        unemployment tables have an error. These data points are rounded
        and should be spelled out to two decimal places for states to
        calculate their points. Accurate data needs to be published for
        comment.

    f.  States need to know the year and source of data used for all
        regression analysis. A schedule of updates to the regression
        analysis needs to made public, each with the year and source of
        data used. New tables need to be shared with states.

    g.  The age and gender cohorts as well as mean visit rate should not
        be updated too often, such as annually. This exposes HPSA
        applications to a moving target and is an uneven application of
        policy. Perhaps a three year cycle would reduce frequent
        variation.

Scoring Issues

1.  The process needs to be developed through a partnership with states.

2.  Scoring criteria should not be published in a final Federal Register
    without an interim rule and comment.

3.  Clinic Population to Clinic Provider FTE should be a variable.

4.  Sliding Fee Scale and Medicaid percent over the Safety Net Facility
    Designation minimum should be developed as a variable.

5.  Because of the difficult populations served by CHCs, many having
    culture and language issues complicating visits, CHCs deserve extra
    points by virtue of being a CHC.

6.  Because of culture and language issues, distance to the next source
    of care is not a reasonable measure for [urban]{.underline} clinics.
    It's unreasonable to assume private providers see these populations.
    Perhaps a measure for urban clinics could consist of percent of
    patients that have a special barrier such as language, homelessness,
    Native American culture, other culture or group with specific health
    complications such as the Marshallese. Perhaps a special population
    variable could be developed.

7.  [Rural]{.underline} Safety Net Facilities should have a distance
    factor associated.

8.  Sole Community Provider should get bonus points.

Sincerely,

![](media/image2.jpeg){width="2.876388888888889in"
height="0.8333333333333334in"}

Joel Young

Manager, Health Systems Planning

Director, Primary Care Office

cc: Jill Canino, Senate Committee on Aging

Eva DuGoff, Office of Senator Ron Wyden

Scott Ekblad, Oregon Office of Rural Health

Craig Hostetler, CEO, Oregon Primary Care Association

Oregon Community Health Center CEO's