Does anyone really understand the reason why there are so many definitions for the terms "medically underserved area" and "health professional shortage area?"
As any healthcare provider who ever submitted a funding application knows, the definitions of those phrases vary depending on the agency, the program, poverty rates, racial or ethnic makeup, various ratios and percentages and distances from one place to another. It's a Tower of Babel out there.
The definitions can change depending on whether the provider is a hospital, a clinic that is "federally qualified," a doctor, a nurse or an allied health professional, and how many people in the region are considered uninsured, or older, and what boundaries are used to define a region.
Infant mortality, rates of fertility and excessive wait times can contribute to the confusing formula as well. Population shifts are also a concern, as some definitions rely on counts from 10-year-old census surveys.
"No one uses the same definition," complains Nina Antonetti, director of Telehealth for the Marshfield Clinic system in Marshfield, Wisconsin, who says she counted no fewer than 120 definitions of "rural," just within the Health Resources and Services Administration.
But billions of dollars are at stake based on these definitions, so it's important to make sure they are meaningful.
That's why HRSA tried in 1998 and 2008 to standardize the definitions, but it got so many letters of complaint that the agency gave up. No matter what the HRSA proposed, some important part of the country would get left out, and another that some insisted should be excluded, would get in.
According to the Federal Register May 11, "In both cases, many public comments were received, and the concerns expressed resulted in an HRSA decision to reconsider and develop a new proposal to be published at a later date; no final revised rule has yet been adopted."
But here it is, 2010, and the Obama administration, known for venturing where others have failed, is trying it again, this time with a different tactic.
Last week, Secretary of Health and Human Services Kathleen Sebelius appointed 28 people across the country to a "negotiated rulemaking" committee (http://bhpr.hrsa.gov/shortage/criteriareview/committee.htm) "to review and update the criteria used to define medically underserved areas and health professional shortage areas."
The idea is that with a "negotiated" process, some of the pitfalls and contentiousness will be sorted out by consensus, without HRSA holding rancorous proceedings. And the HRSA process of actually making the rule will go much more smoothly.
At least that's the hope.
The geographically diverse appointees, charged with muddling through various definition scenarios, hail from Hawaii to New Hampshire and from Alaska to Georgia. They represent community health centers, hospitals and clinics in rural areas, special populations with unique healthcare needs, and technical experts in research dealing with healthcare professions, access and statistics.
And they are ethnically diverse with a varied range of constituencies. For example, one member of the committee is Sherry Hirota, director of Asian Health Services in Oakland CA. Patrick Rock, MD, is chief executive director of the Milwaukee Indian Health Board.
"Every effort was made to maintain a geographic and demographic representation for this committee," said Mary Wakefield, HRSA Administrator. "The committee will begin meeting later this year and be open to the public in the interest of transparency."
The problem is a difficult one. For example, in West Virginia, healthcare providers in a critical access hospital in Beckley serve a very rural area that sits 25 miles from several towns considered metropolitan. But to get to the next health care facility requires a long and windy drive through Appalachian roads.
The hospital and clinic in Beckley are excluded from certain types of funding they think they should have, Antonetti says.
Health reform legislation makes it clear that Congress is serious about addressing healthcare disparities in these two areas. Consideration is given for qualifying providers specializing in depression, stroke, pediatrics, home health care, and veterans to name a few areas. There are loan programs for physicians, allied health professionals, certain surgical specialists willing to work in these designated areas.
According to the HRSA statement, an area must be designated as a HPSA to be eligible for placement of National Health Service Corps providers, and the MUP designation is used to award grants to community health centers.
"A variety of other federal and state programs also use these designations to target resources to areas of need," the HRSA statement says.
One committee appointee is Mark Babitz, MD, director of the division of Family and Health Preparedness for the Utah Department of Health in Salt Lake City. He hopes that the committee finds a way to combine the two phrases into one consistent and clear definition.
And rather than looking just at census tracts or county lines, he says, "We should ask in each community 'Where do people go for health care? Where do they go for primary care and for specialist care and for hospital care?'" And, he adds, is there a way to improve their ability to access that care by bringing it closer?
"Sometimes lines are arbitrary," he acknowledges. "I don't think the system is totally broken. But if I add a census track, do I add it because I'm going to serve them or do I add it to make my numbers look better?
"There are a lot of politics at work behind how we define these areas."
One place this battle is playing out is in western Utah, where a large community health system struggling to serve a 700-square mile area is fighting efforts of much smaller community clinic that wants to become a federally qualified health system. Such a designation would take money away from the larger organization because of the way medically underserved definitions have been set. "It would rob Peter to pay Paul and neither option serves the community," Babitz says.
Another newly appointed committee member, Alice Larson of Vashon Island, WA, says she wants to make sure federal definitions don't leave out migrant farmworkers, and the homeless, populations that are often undercounted when federal funds roll out, but who need healthcare nevertheless.
Additionally, it's important not to just count the number of providers in an area, but the number who will see people who don't speak English or who can't pay. "Just using a physician-to-population ratio doesn't cut it; you have to know those physicians are accessible."
She says federal definitions should recognize that use of census in rural areas is often fraught with error. For example, a community of 20,000 might be said to have a poverty rate of 25%, but the census is only re-examined every five years, with a margin of error of 5%. That means the region could have between 4,000 and 6,000 people living in poverty. That's a big difference, she says.
Babitz, who describes himself as an advocate for rural health care interests and was a National Health Service Corps physician for nine years, is aware how difficult the task may ultimately be. And he's aware that previous administrative efforts failed.
But this time, he says, "I'm optimistic."
By bringing in the various constituency groups to hash it out, and "develop the rule that short-circuits the rulemaking process with much less resistance, fewer negative comments, and in a way that speeds up the process."
"I have some faith in this negotiated rulemaking process. It'll be work but great experience," Babitz says.
The committee is scheduled to present its "draft final" proposal a year from now. Let's hope they succeed.