Effectiveness of Workforce
Programs in Improving Healthcare
Access in Maryland
Jamilah Shakir, MD
PHASE Symposium
May 9, 2014
Outline
• Project Introduction/Overview
• HPSA designation
• Workforce Programs
•
•
•
•
Methods/Approach
Findings
Limitations and Challenges
Conclusions/Policy and Practice Implications
HPSA Designations
Primary Care (PC) HPSA
• Provider: population ratio
≥1:3500
• Percent of population
with income less than
poverty level
• Travel distance/time to
nearest source of
accessible care outside the
HPSA
• Infant health index
• Infant mortality rate
• Low-birth weight
HRSA Primary Medical Care HPSA Designation Criteria 1993
HRSA Mental Health HPSA Designation Criteria 1993
Mental Health (MH) HPSA
• Psychiatrist: population
ratio >1:30,000
• Percent of population
with incomes less than
poverty level
• Travel distance/time to
nearest source of
accessible care outside the
HPSA
• Additional factors
•
•
•
•
Youth Ratio
Elderly Ratio
Substance abuse prevalence
Alcohol abuse prevalence
Workforce Programs
• National Health Service Corp (NHSC)
• J1 Visa Waiver
• State Loan Assistance Repayment Program
(SLRP)
National Health Service Corp
• NHSC Scholarship
• Enrolled or accepted students committed to
primary care
• 2-4 yr. full-time service requirement at HPSA
designated sites
• NHSC Loan Repayment
• Receive educational loan repayment up to
$50,000
• 2 yr. full-time service at a HPSA designated site
U. S. Department of Health and Human Services: National Health Services Corp official website: https://nhsc.hrsa.gov
J-1 Visa Waiver Program
• Granted for the physician's agreement to
work in an underserved area for 3 years
• Annual state eligibility: 30 J-1 Visa waivers
Maryland Department of Health and Mental Hygiene J1 Visa Waiver Policy, revised May 2013 http://hsia.dhmh.maryland.gov/opca/J1%20Visa%20app%20materials/J‐1%20MD%20Policy.doc
Maryland State Loan
Repayment Program (SLRP)
• Primary Care Physicians ONLY
• 2-4 yr. full-time service commitment
• Loan repayment assistance $25,000/yr
• Maximum assistance $100,000
Maryland Department of Health and Mental Hygiene: State Loan Repayment Program (SLRP) in Maryland. http://hsia.dhmh.maryland.gov/opca/SitePages/pco‐larp.aspx
Objectives
1. To determine the effectiveness of federal workforce
programs in improving primary care and mental health
access in Maryland from 2003-2012
2. To determine trends in primary care and mental health
HPSA designations and workforce providers from 20032012.
Outcome Measures
1. Healthcare access (primary care and mental health)
1) Provider: population ratios
2) Respondent answer to Maryland BRFSS Healthcare Access
question
a) Was there a time in the past 12 months when you needed to see a
doctor but could not because of the cost?
2. Number of primary care and mental health HPSA
designations (2003-2012)
3. Number of primary care and mental health workforce
providers per county (2003-2012)
Study Design/ Methodology
• Four Data Sources
• HRSA Data Warehouse
• J-1 Visa Waiver Program, NHSC and SLRP
workforce provider placements
• HRSA Area Resource file
• Maryland BRFSS
• Statistical Analysis
• T-test
• Descriptive analysis
Maryland
Maryland HPSA Designations
(2003-2012)
Primary Care HPSA
• Total Number
Mental Health HPSA
• Total Number
• 297
• 139
• Average
• Average
• 29.7 HPSAs/year
• 13.9 HPSAs/year
2003
2004
2005
2006
2007
Year
2008
2009
2010
2011
2012
SLRP
NHSC
J1 Visa Waiver
SLRP
NHSC
J1 Visa Waiver
SLRP
NHSC
J1 Visa Waiver
SLRP
NHSC
J1 Visa Waiver
SLRP
NHSC
J1 Visa Waiver
SLRP
NHSC
J1 Visa Waiver
SLRP
NHSC
J1 Visa Waiver
SLRP
NHSC
J1 Visa Waiver
SLRP
NHSC
J1 Visa Waiver
SLRP
NHSC
J1 Visa Waiver
No. Primary Care Providers
Maryland Primary Care Providers by Workforce Program
140
120
100
80
60
40
20
0
2003
2004
2005
2006
2007
Year
2008
2009
2010
2011
2012
SLRP
NHSC
J1 Visa Waiver
SLRP
NHSC
J1 Visa Waiver
SLRP
NHSC
J1 Visa Waiver
SLRP
NHSC
J1 Visa Waiver
SLRP
NHSC
J1 Visa Waiver
SLRP
NHSC
J1 Visa Waiver
SLRP
NHSC
J1 Visa Waiver
SLRP
NHSC
J1 Visa Waiver
SLRP
NHSC
J1 Visa Waiver
SLRP
NHSC
J1 Visa Waiver
No. of Psychiatrists Maryland Psychiatrists by Workforce Program 16
14
12
10
8
6
4
2
0
Maryland Primary Care Provider: Population Ratio (per 100,000 residents)
9
PP Ratio (per 100,00 residents)
8.5
8
7.5
7
6.5
WF
‐WF
2003
WF
‐WF
2004
WF
‐WF
2005
WF
‐WF
2006
WF
‐WF
2007
Year
WF
‐WF
2008
WF
‐WF
2010
WF
‐WF
2011
Maryland Psychiatrist: Population Ratio (per 100,000 residents)
1.65
PP Ratio (per 100,000 residents)
1.6
1.55
1.5
1.45
1.4
1.35
1.3
1.25
WF
‐WF
2003
WF
‐WF
2004
WF
‐WF
2005
WF
‐WF
WF
2006
‐WF
2007
Year
WF
‐WF
2008
WF
‐WF
2010
WF
‐WF
2011
Maryland BRFSS Survey:
Healthcare Access by County
Question #3: Was there a time in the past 12 months when you needed to see a doctor but could not because of the cost? 1. Queen Anne's County (7.18%)
2. Calvert County (7.68%)
3. Howard Co. (8.3%)
4. Hartford County (9.14%)
5. Charles County (9.2%)
6. Fredrick County (9.36%)
7. Carroll County (9.38%)
8. Anne Arundel County (9.56%)
Worcester County (9.56%)
9. St. Mary's County (9.75%)
10. Montgomery County (10.14%)
11. Talbot County (10.17%)
12. Washington County (10.24%)
13. Dorchester County (10.92%)
14. Kent County (11.07%)
Mean Maryland (11.46% +/‐ 1.15)
15. Baltimore County (11.9%)
16. Cecil County (12.33%)
Allegany County (12.33%)
17. Wicomico County (12.63%)
18. Garrett County (14.12%)
19. Prince Georges County (14.13%)
20. Caroline County (15.71%)
21. Baltimore City (15.97%)
22. Somerset County (16.93%)
Limitations and Challenges
• Having complete data available to answer the proposed question
• Generalizability of findings
• Provider: population ratios
• Cannot infer adequacy of provider resources and improved healthcare access for the population
• No consideration of services provided by non‐
physician providers
• Maryland BRFSS Healthcare Access Question
Conclusion
• Little to no impact of workforce programs on
improving primary care and mental health
access in Maryland
• More work needs to be done to include nonphysician primary care and mental health
providers in workforce programs to improve
healthcare access
Acknowledgements
• Elizabeth Vaidya
• Kade Patanavanich
• Raquel Samson, MPH
• Karen Matsuoka, PhD
References
1.
2.
3.
4.
5.
HRSA Primary Medical Care HPSA Designation Criteria. Relevant
Excerpts from 42 Code of Federal Regulations (CFR), Chapter 1, Part 5,
Appendix C (October 1, 1993 pp34-48). Retrieved from:
http://bhpr.hrsa.gov/shortage/hpsas/designationcriteria/primarycarehpsa
criteria.html
HRSA Mental Health HPSA Designation Criteria. Relevant Excerpts
from 42 Code of Federal Regulations (CFR), Chapter 1, Part 5, Appendix
C (October 1, 1993 pp34-48). Retrieved from:
http://bhpr.hrsa.gov/shortage/hpsas/designationcriteria/mentalhealthhps
acriteria.html
U. S. Department of Health and Human Services: National Health
Services Corp official website. Retrieved on 4/9/14 from:
https://nhsc.hrsa.gov
Maryland Department of Health and Mental Hygiene J1 Visa Waiver
Policy, revised May 2013. Retrieved from:
http://hsia.dhmh.maryland.gov/opca/J1%20Visa%20app%20materials/J1%20MD%20Policy.doc
Maryland Department of Health and Mental Hygiene: State Loan
Repayment Program (SLRP) in Maryland. Retrieved on 4/8/2014 from
http://hsia.dhmh.maryland.gov/opca/SitePages/pco-larp.aspx
Questions??