Transforming Rural Access: A Blueprint for State Workforce Data Capacity
Author: Eric Turer
The roll-out of the federal Rural Health Transformation (RHT) funds over the next 5 years represents a historic opportunity for states to make meaningful inroads into addressing the access issues faced by rural communities. It also presents an unprecedented challenge in terms of targeting resources and evaluating program impacts in rural areas. Many states have, rightfully, elected to focus on primary care provider availability, accessibility, and distribution within their planned initiatives. Having worked for over 3 decades with states across the country, and directly with the federal agencies responsible for access and workforce, I know that most states do not have systems in place to collect and/or analyze the full range of provider data needed to most effectively target and evaluate the results of the RHT. The RHT is the perfect opportunity to implement such systems; with benefits that will long outlast the grant funding.
State Primary Care Offices (PCOs) are typically the agency tasked with collecting and managing provider workforce data, primarily related to evaluating and maintaining federal Health Professional Shortage Area (HPSA) and Medically Underserved Area/ Populations (MUA/P) designations – a narrowly defined view of workforce and access. PCOs must now document provider data in the Shortage Designation Management System (SDMS), set up by the Bureau of Health Workforce (BHW). This system is primarily a data entry and management tool, which provides little assistance in the process of gathering and integrating the sources of data needed to populate it, and does not offer tools for analyzing access and workforce issues beyond what is needed for processing federal designations. Further, the PCOs’ mandate focuses only on those physicians and dentists covered by the designation process, capturing limited information and omitting data on the many other provider categories involved in primary care. Lastly, PCO internal expertise and funding typically can’t support the database and geographic information system (GIS) skills needed for development of a fully functional provider workforce data resource.
Utilizing the RHT resources available in the short-term, states can undertake a range of practical steps to close these gaps by implementing systems and processes that will persist beyond the RHT funding window. Developing tools to routinely collect and to meaningfully integrate and analyze comprehensive workforce data on the full range of healthcare providers will establish a platform that can unlock the value of this information and be readily deployed in subsequent years with considerably less effort. These are my top recommendations – all based on efforts successfully implemented with various states:
Establish Electronic Provider Surveys in Collaboration with State Licensing Boards: Much of the key information needed for true provider analysis is still best obtained via survey. State licensing boards generally do not have the mandate or resources to conduct provider surveys, yet they are the definitive authority over who is and isn’t able to practice in the state. In several states, the Boards have been willing to become collaborators with PCOs in the provider survey process by assuring that they will not bear the cost or burden of implementing such surveys, or of analyzing the results. They need only present a link to a pre-developed electronic survey, with a license-specific password, as part of their licensing and renewal process. Providing an affirmative ‘opt out’ is important, as completing a survey generally cannot be legally required, but most providers participate willingly, and reminders can be sent. Such surveys can gather data on the provider themselves, and importantly on their specific work at each individual location where they practice. Once the resulting data is cleaned and analyzed, it becomes a foundational part of the workforce data system and may also be shared back to the Board.
Establish Routine Claims Data Capacity Analysis: Claims data can provide an incredibly valuable view of provider capacity and accessibility, yet acquiring, managing, and analyzing it correctly can be a challenge for a state PCO. The federal designation systems have long allowed Medicaid office-visit claims to be used as a proxy for Medicaid provider capacity, yet no guidance has been given regarding the key parameters needed to use it properly. Defining the range of Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes of interest, determining which of several possible NPI numbers on a claim to use and for which purpose, filtering multiple provider taxonomy codes to define what will be considered primary care, and identifying issues with billing under organizational vs individual National Provider Identifier (NPI) numbers, are all key considerations that must be carefully addressed. Data use agreements (DUAs) and Business Associate Agreements (BAAs) must also be carried out. For states with an All-Payer Claims Data (APCD) system, using these can greatly enhance the value of the claims analysis effort to examine disparities by payor, while also providing Medicaid results for designation.
Conduct Claims Data Origin-Destination Analysis: An even more powerful use of claims data is unlocked by simply including the patient’s zip code in the data elements requested. By developing a matrix that pairs the patient’s zip code with the zip code of the provider seen and attributing a GIS derived drive time to the count of visits following those Origin-Destination zip pairs, the details of actual access patterns can be directly observed, mapped, and quantified at a geographically detailed level. This approach has utility in identifying rural pockets of need and creating rural-sensitive service areas that don’t mask rural needs or merge them into adjacent population centers. Attributes such as the average visit-weighted drive time, the primary destination for care, the percent of visits following that pattern, and even utilization rates by member-year, can be readily calculated and mapped. Even telehealth can be separated and examined to see which patients utilize those services. Patient zip codes can be connected to the Census/ACS ZCTA-level data to examine associated community characteristics.
Develop a Unified Provider Data Repository and Analysis Platform: Rather than holding provider data separately for each provider category and year, developing a unified data structure to consolidate all provider data single database truly unlocks the ability to examine the composition of the workforce and how it is changing or responding to initiatives. The basic content of all workforce data, regardless of the source or provider category, can be fit into a table of characteristics related to the individual, and a related table of characteristics regarding the work they perform at different locations. By connecting this database to data visualization, statistics, and mapping tools, the full content of the provider information across provider types and over time can be unlocked.
There has never been a better opportunity, or a more important time, to build out your state’s provider workforce data capacity.
Author: Eric S Turer, MBA – Health Systems Administration, worked as a senior public-health consultant with JSI for over 30 years, during which he consulted with states and federal agencies on programs and policies promoting primary care access. He has also served as the President of the 6-state New England Rural Health Association, and is currently a NH State Representative.