Health Professional Shortage Areas
Problems Remain with Primary Care Shortage Area Designation System Gao ID: GAO-07-84 October 24, 2006To identify areas facing shortages of health care providers, the Department of Health and Human Services (HHS) relies on its health professional shortage area (HPSA) designation system. HHS designates geographic, population-group, and facility HPSAs. HHS also gives each HPSA a score to rank its need for providers relative to other HPSAs. The Health Care Safety Net Amendments of 2002 required GAO to report on the HPSA designation system. GAO reviewed (1) the number and location of HPSAs and federal programs that use HPSA designations to allocate resources or provide benefits, (2) available research on HPSA designation criteria and methodology, and (3) the impact of a 2002 provision that automatically designates federally qualified health centers and certain rural health clinics as facility HPSAs. GAO obtained and analyzed HHS's data on primary care HPSA designations as of September 2005 and January 2006 and identified reports on HPSA criteria and methodology through a literature search of peer-reviewed journals and other reports published since 1995.
GAO identified more than 5,500 HPSAs designated throughout the United States as of September 2005; multiple federal programs relied on these designations to allocate resources or provide benefits. GAO estimated that slightly more than half of the HPSAs were designated for geographic areas--such as counties or portions of counties--or population groups, such as migrant farmworkers. The remaining HPSAs were designated for facilities, such as rural health clinics. In fiscal year 2005, more than 30 federal programs relied on HPSA designations, and in some cases HPSA scores, to allocate resources or provide benefits. The use of the HPSA designation by numerous federal programs to allocate resources or provide benefits is an incentive for obtaining and retaining a HPSA designation. Published reports have pointed to shortcomings in the methodology used for designating HPSAs. These reports' observations were consistent with findings in GAO's 1995 report, Health Care Shortage Areas: Designations Not a Useful Tool for Directing Resources to the Underserved, (GAO/HEHS-95-200, Sept. 8, 1995), including that HHS's methodology did not account for certain types of primary care providers already serving in a HPSA, which can result in an overstatement of the provider shortage. Recognizing the shortcomings of the current methodology, HHS has been working since 1998 on a proposal to revise the designation system. In addition, some HPSAs that no longer meet the criteria have retained their HPSA designation and possibly received benefits from federal programs that rely on that designation. HHS has not complied since 2002 with the statutory requirement to annually publish a list of designated HPSAs in the Federal Register--which would remove the designations of those HPSAs that are no longer listed. Many federally qualified health centers and rural health clinics did not benefit from automatic designation as facility HPSAs because they were located in geographic or population-group HPSAs. In addition, most of the more than 1,600 federally qualified health centers received HPSA scores associated with the automatic designation that were too low to qualify them for certain federal programs that required a minimum HPSA score in 2005, although they qualified for other programs that did not have such a requirement. Of the 590 rural health clinics that chose to certify that they would treat anyone regardless of ability to pay and, as a result, received automatic designation as facility HPSAs, most also received associated HPSA scores too low to qualify for benefits from certain federal programs that required a higher HPSA score.
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Report to Congressional Committees:
United States Government Accountability Office:
GAO:
October 2006:
Health Professional Shortage Areas:
Problems Remain with Primary Care Shortage Area Designation System:
Health Professional Shortage Areas:
GAO-07-84:
GAO Highlights:
Highlights of GAO-07-84, a report to congressional committees
Why GAO Did This Study:
To identify areas facing shortages of health care providers, HHS relies
on its health professional shortage area (HPSA) designation system. HHS
designates geographic, population-group, and facility HPSAs. HHS also
gives each HPSA a score to rank its need for providers relative to
other HPSAs.
The Health Care Safety Net Amendments of 2002 required GAO to report on
the HPSA designation system. GAO reviewed (1) the number and location
of HPSAs and federal programs that use HPSA designations to allocate
resources or provide benefits, (2) available research on HPSA
designation criteria and methodology, and (3) the impact of a 2002
provision that automatically designates federally qualified health
centers and certain rural health clinics as facility HPSAs. GAO
obtained and analyzed HHS‘s data on primary care HPSA designations as
of September 2005 and January 2006 and identified reports on HPSA
criteria and methodology through a literature search of peer-reviewed
journals and other reports published since 1995.
What GAO Found:
GAO identified more than 5,500 HPSAs designated throughout the United
States as of September 2005; multiple federal programs relied on these
designations to allocate resources or provide benefits. GAO estimated
that slightly more than half of the HPSAs were designated for
geographic areas, such as counties or portions of counties, or
population groups, such as migrant farmworkers. The remaining HPSAs
were designated for facilities, such as rural health clinics. In fiscal
year 2005, more than 30 federal programs relied on HPSA designations,
and in some cases HPSA scores, to allocate resources or provide
benefits. The use of the HPSA designation by numerous federal programs
to allocate resources or provide benefits is an incentive for obtaining
and retaining a HPSA designation.
Published reports have pointed to shortcomings in the methodology used
for designating HPSAs. These reports‘ observations were consistent with
findings in GAO‘s 1995 report, Health Care Shortage Areas: Designations
Not a Useful Tool for Directing Resources to the Underserved, (GAO/HEHS-
95-200, Sept. 8, 1995), including that HHS‘s methodology did not
account for certain types of primary care providers already serving in
a HPSA, which can result in an overstatement of the provider shortage.
Recognizing the shortcomings of the current methodology, HHS has been
working since 1998 on a proposal to revise the designation system. In
addition, some HPSAs that no longer meet the criteria have retained
their HPSA designation and possibly received benefits from federal
programs that rely on that designation. HHS has not complied since 2002
with the statutory requirement to annually publish a list of designated
HPSAs in the Federal Register”which would remove the designations of
those HPSAs that are no longer listed.
Many federally qualified health centers and rural health clinics did
not benefit from automatic designation as facility HPSAs because they
were located in geographic or population-group HPSAs. In addition, most
of the more than 1,600 federally qualified health centers received HPSA
scores associated with the automatic designation that were too low to
qualify them for certain federal programs that required a minimum HPSA
score in 2005, although they qualified for other programs that did not
have such a requirement. Of the 590 rural health clinics that chose to
certify that they would treat anyone regardless of ability to pay and,
as a result, received automatic designation as facility HPSAs, most
also received associated HPSA scores too low to qualify for benefits
from certain federal programs that required a higher HPSA score.
What GAO Recommends:
GAO recommends that HHS
(1) remove the designations of HPSAs that no longer qualify by
publishing a list of designated HPSAs in the Federal Register and (2)
complete and publish HHS‘s proposal to revise the HPSA designation
system. HHS concurred with both recommendations.
[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-84].
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Leslie G. Aronovitz at
(312) 220-7600 or aronovitzl@gao.gov.
[End of Section]
Contents:
Letter:
Results in Brief:
Background:
HPSAs Are Located in Every State and Are Used by Multiple Federal
Programs:
Research Points to Shortcomings with Designation Methodology:
Many Health Centers and Rural Health Clinics Did Not Benefit from
Automatic HPSA Designation:
Conclusions:
Recommendations for Executive Action:
Agency Comments:
Appendix I: Scoring of Health Professional Shortage Areas:
Appendix II: Medically Underserved Area or Population Designations and
Medically Underserved Community Definition:
Appendix III: Scope and Methodology:
Appendix IV: Federal Programs Using Health Professional Shortage Area
and Other Designations of Underservice:
Appendix V: Comments from the Department of Health and Human Services:
Appendix VI: GAO Contact and Staff Acknowledgments:
Related GAO Products:
Tables:
Table 1: Number of, Population in, and Physicians Needed in Geographic
and Population-Group HPSAs, September 2005:
Table 2: Programs and Administering Agencies That Used HPSA, MUA, MUP
or Other Designations to Allocate Resources or Provide Benefits in
Fiscal Year 2005:
Figures:
Figure 1: HPSA Designation Request and Review Process, 2005:
Figure 2: Types of HPSAs and Criteria Used to Designate Them, 2005:
Figure 3: U.S. Counties with Geographic and Population-Group HPSAs,
January 2006:
Figure 4: Types of Facility HPSAs, September 2005:
Figure 5: Distribution of HPSA Scores among Health Centers
Automatically Designated as Facility HPSAs, September 2005:
Figure 6: Distribution of HPSA Scores among Rural Health Clinics
Automatically Designated as Facility HPSAs, September 2005:
Figure 7: Scoring of HPSAs, 2005:
Abbreviations:
CMS: Centers for Medicare & Medicaid Services:
COGME: Council on Graduate Medical Education:
HHS: Department of Health and Human Services:
HPSA: health professional shortage area:
HRSA: Health Resources and Services Administration:
IHS: Indian Health Service:
MUA: medically underserved area:
MUP: medically underserved population:
NHSC: National Health Service Corps:
USCIS: U.S. Citizenship and Immigration Services:
VA: Department of Veterans Affairs:
United States Government Accountability Office:
Washington, DC 20548:
October 24, 2006:
The Honorable Michael B. Enzi:
Chairman:
The Honorable Edward M. Kennedy:
Ranking Minority Member:
Committee on Health, Education, Labor, and Pensions:
United States Senate:
The Honorable Richard Burr:
Chairman:
Subcommittee on Bioterrorism and Public Health Preparedness:
Committee on Health, Education, Labor, and Pensions:
United States Senate:
The Honorable Joe Barton:
Chairman:
The Honorable John D. Dingell:
Ranking Minority Member:
Committee on Energy and Commerce:
House of Representatives:
Many Americans live in areas, such as inner-city neighborhoods or
isolated rural locations, where obtaining health care is difficult
because health care providers are in short supply. To identify areas
facing a critical shortage of providers, the Department of Health and
Human Services (HHS) relies on its health professional shortage area
(HPSA) designation system.[Footnote 1] Originally created in 1978 to
identify areas in need of physicians and other health care providers
from HHS's National Health Service Corps (NHSC) programs, HPSA
designation is now used by a variety of federal programs--including
programs that provide grants for health professions education and
training or bonus payments under Medicare for physician services--to
allocate resources or provide benefits.[Footnote 2]
A HPSA can be a distinct geographic area (such as a county), a specific
population group within an area (such as low-income individuals), or a
specific health care facility. Facility HPSAs include federal or state
correctional institutions, as well as federally qualified health
centers--facilities that provide primary care services in underserved
areas[Footnote 3]--and certain rural health clinics--facilities that
provide outpatient primary care services in rural areas.[Footnote 4]
HHS's Health Resources and Services Administration (HRSA)--the HHS
agency that manages the HPSA designation system--designates HPSAs based
on the ratio of population to the number of primary care physicians and
other factors.[Footnote 5] HRSA then assigns each HPSA a score on the
basis of specific criteria that ranks its shortage of primary care
providers, or need, relative to other HPSAs.[Footnote 6] Some federal
health care programs, such as NHSC programs, allocate their resources
on the basis of HPSA scores, not just HPSA designations.
HHS's criteria and methodology for designating HPSAs has remained
unchanged since October 1, 1993.[Footnote 7] In 1998, in an effort to
improve the way underserved areas were designated, HHS published a
proposal to revise the HPSA designation system.[Footnote 8] The
department received more than 800 comments on its proposal from
individuals and organizations, including individual physicians, state
primary care organizations, and university or research organizations.
These comments raised several issues, such as whether or how to count
nonphysician providers, such as physician assistants, in the total
number of practitioners serving a population; the potential number of
HPSAs that would lose their HPSA designations because of changes in the
designation criteria; and the incorporation of certain population
factors, such as the percentage of elderly and uninsured individuals,
which reflect a population's ability to access care. In response to
these comments, HHS withdrew its 1998 proposal, and left the existing
HPSA designation system in place while it began working on another
proposal.
The Health Care Safety Net Amendments of 2002 required that we report
on the HPSA designation system and on a provision included in the act
that automatically designates health centers and certain rural health
clinics as facility HPSAs.[Footnote 9] As discussed with the committees
of jurisdiction, this report discusses (1) the number and location of
HPSAs and the federal programs that use HPSA designations to allocate
resources or provide benefits, (2) available research on the criteria
and methodology used to designate HPSAs, and (3) the impact of the
automatic HPSA designation on health centers and rural health clinics.
To conduct our work, we examined relevant laws, regulations, and HHS
documents related to the HPSA criteria in effect in 2005--criteria that
had remained unchanged since 1993--and reviewed our prior work on the
HPSA designation system. To determine the number of HPSAs, we
interviewed officials from HRSA, who reported that precise, accurate,
historical data on the total number of HPSAs were not available.
Therefore, to estimate the number of HPSAs designated as of September
2005, we designed a methodology that used data from HRSA, including
summary statistics on geographic and population-group HPSA designations
and data files on the facilities that were automatically designated as
HPSAs. We also analyzed a more detailed database of geographic and
population-group HPSAs as of January 2006 in order to identify (1) the
counties in which geographic and population-group HPSAs were located
and (2) the HPSAs that were proposed for having their designations
withdrawn because they no longer met the criteria or did not provide
updated data in support of their designations. After taking steps to
eliminate potential duplications or inconsistencies in the data we
used, we determined that the data were sufficiently reliable for our
purposes. To obtain information on HPSA designations and federal
programs that use HPSA designations, we reviewed Federal Register
notices and other documents obtained from HHS agencies--including HRSA,
the Centers for Medicare & Medicaid Services (CMS), and the Indian
Health Service (IHS)--and reviewed our prior work on these programs.
To identify available research on the criteria and methodology used to
designate HPSAs, we conducted a literature search of reports, including
those published in peer-reviewed journals, issued from January 1, 1995,
through November 1, 2005. We identified other published reports
discussing the HPSA designation methodology, including one by the
Council on Graduate Medical Education (COGME). Of the more than 340
articles, studies, and reports--which we refer to as reports--
identified in the search, we identified 7 that addressed the
relationship between key elements of the HPSA designation criteria,
such as income, and primary care physician supply or shortages, or that
addressed factors related to the HPSA designation methodology. We also
interviewed researchers who have studied primary care provider
shortages, as well as HRSA officials knowledgeable about the HPSA
designation system. To review the impact of the automatic designation
on health centers and rural health clinics, we analyzed HRSA's data on
automatic HPSA designations, including the HPSA scores associated with
automatic designation, and interviewed HRSA officials and officials
from associations representing these types of facilities. We performed
our work from August 2005 through September 2006 in accordance with
generally accepted government auditing standards.[Footnote 10]
Results in Brief:
We identified more than 5,500 HPSAs designated throughout the United
States as of September 2005; multiple federal programs relied on these
designations to allocate resources or provide benefits. We estimated
that slightly more than half of the HPSAs were designated for
geographic areas or population groups, and these geographic and
population-group HPSAs were located in all 50 states and the District
of Columbia. Facility HPSAs, which accounted for slightly less than
half of the total number of HPSAs, were also located in every state and
the District of Columbia. In fiscal year 2005, more than 30 federal
programs--including programs administered by HRSA, CMS, and federal
agencies outside of HHS--relied on HPSA designations and, in some
cases, HPSA scores, to allocate resources or provide benefits. These
included NHSC programs that award scholarships or educational loan
repayment to students and health professionals in exchange for a
commitment to practice in HPSAs for at least 2 years. Other programs
relying on HPSA designations to allocate resources or provide benefits
included programs that pay physicians bonus payments for services
provided to Medicare beneficiaries in geographic HPSAs and programs
that waive certain requirements for foreign physicians if they agree to
practice in HPSAs or other underserved areas of the United States. The
use of the HPSA designation by numerous federal programs to allocate
resources or provide benefits is an incentive for obtaining and
retaining a HPSA designation.
Of the seven reports we identified that discuss the criteria and
methodology used to designate HPSAs, one supported a relationship
between a key element of the HPSA criteria and primary care physician
supply, while the remaining six pointed to shortcomings in the
methodology. The one report we identified that supported a key element
of the criteria found that areas with higher incomes had more primary
care physicians than areas with lower incomes. The other six reports
included observations that were consistent with what we reported in
1995, including the fact that the HPSA designation methodology does not
account for the presence of certain types of primary care providers in
a HPSA, which can result in an overstatement of the shortage of primary
care providers. Researchers have highlighted other problems in the
methodology used to designate HPSAs, such as relying on geographic
boundaries that do not necessarily reflect areas' health care needs.
Recognizing the shortcomings of the current methodology, HHS has been
working since 1998 on a proposal to revise the HPSA designation system,
which, as of September 2006, was in the department's clearance process.
In 1995, we reported on an additional problem involving the timeliness
with which HRSA identified and removed the HPSA designations of those
areas, population groups, and facilities that no longer met the HPSA
criteria--a problem that has continued in recent years. For example, in
2005, the HHS Office of Inspector General reported that, as of 2003,
HRSA had not reviewed HPSA designations in a timely manner. In
addition, we found that since 2002, HHS has not complied with the
statutory requirement to annually publish a list of designated HPSAs in
the Federal Register or otherwise remove the HPSA designations for
those HPSAs that either no longer meet the criteria or have not
provided updated data in support of their designations. As a result,
some HPSAs that no longer meet the criteria have retained their HPSA
designations and possibly received benefits from federal programs that
rely on the designation for allocating resources.
Automatic HPSA designation of health centers and certain rural health
clinics as facility HPSAs provided little or no benefit for many of
these facilities. For health centers and rural health clinics located
in geographic or population-group HPSAs before implementation of the
2002 provision, automatic designation as a facility HPSA resulted in no
added benefit unless the HPSA score associated with the automatic
designation was higher than the score for the geographic or population-
group HPSA in which the facility was located. Although precise data
were not available, HRSA officials estimated that many of the more than
1,600 health centers--all of which received automatic designation as
facility HPSAs--were located in geographic or population-group HPSAs
before 2002. Of the more than 3,600 rural health clinics, 590 had
certified they would treat everyone regardless of ability to pay and,
as a result, received automatic HPSA designation as of September 2005;
however, data were not available to determine how many of them were
located in geographic or population-group HPSAs before receiving
automatic HPSA designation. In addition, although officials that work
with health centers and rural health clinics reported that these
facilities in general welcomed the automatic HPSA designation because
it could allow them the benefit of recruiting a physician through the
NHSC, few had HPSA scores associated with the automatic designation
that were high enough to qualify for a physician through the NHSC
Scholarship Program. Specifically, as of September 2005, less than 5
percent of the health centers and less than 1 percent of the rural
health clinics with automatic facility HPSA designations had HPSA
scores that were high enough to qualify for a physician through the
NHSC Scholarship Program. However, all health centers and rural health
clinics that received automatic designations as HPSAs, even those with
lower HPSA scores, could apply in 2005 for a health care provider
through another NHSC program, the NHSC Loan Repayment Program.
We are recommending that HHS (1) publish a list of designated HPSAs in
the Federal Register or otherwise remove, through Federal Register
notification, the HPSA designations for those HPSAs that no longer meet
the criteria or have not provided updated data demonstrating they still
meet the designation criteria and (2) complete and publish HHS's
proposal to revise the HPSA designation system and address the problems
that have been identified in the current methodology for designating
HPSAs.
In commenting on a draft of this report, HHS concurred with our
recommendations. Specifically, the department agreed that more timely
publication of a list of designated HPSAs in the Federal Register is
necessary, noting that publication in the Federal Register ensures that
those HPSAs that have been proposed for withdrawal have their
designations removed. The department also agreed with our
recommendation to complete and publish its proposal to revise its HPSA
designation system, stating that its proposal would address the various
shortcomings that we have identified in this and previous reports.
Background:
Any agency or individual may request a HPSA designation for a
geographic area, population group, or facility.[Footnote 11] According
to HRSA officials, the vast majority of HPSA designation requests are
submitted by state primary care offices.[Footnote 12] These requests
are received and reviewed by the Shortage Designation Branch within
HRSA. Individual and agency requesters, other than state primary care
offices, are required to submit a copy of their request for HPSA
designation to their state's primary care office. The state primary
care office solicits comments about the request from state groups,
including the state health department and state professional
associations, and forwards the comments to HRSA. Other interested
parties may also provide comments on the request and submit the
comments directly to HRSA. HRSA's final designation decision is based
on a review of the request and comments received from the state and
other interested parties (see fig. 1).
Figure 1: HPSA Designation Request and Review Process, 2005:
[See PDF for image]
Source: GAO analysis of relevant statutes, regulations, and guidance.
[A] Primary care associations are private, nonprofit organizations
representing states or regions that provide training and technical
assistance to facilities, including health centers, to help ensure that
these facilities deliver high-quality primary care services in
underserved communities. For more information, see HRSA, Bureau of
Primary Health Care, "Directory of Primary Care Associations (PCA):
April 2005," http://bphc.hrsa.gov/OSNP/PCADirectory.htm (downloaded
Apr. 3, 2006).
[End of figure]
HRSA designates three types of HPSAs: geographic, population-group, and
facility. Geographic HPSAs include entire counties, a portion of a
county, or a group of contiguous counties. Population-group HPSAs
include groups, such as migrant farmworkers, low-income urban
populations, or federally recognized Native American Tribes or Alaska
Natives, within a particular geographic area. Facility HPSAs include
federal or state correctional institutions, health centers, and certain
rural health clinics. To receive HPSA designation, the requesting
agency or individual must provide HRSA with information demonstrating
that the area, population group, or facility meets applicable criteria
(see fig. 2).[Footnote 13]
Figure 2: Types of HPSAs and Criteria Used to Designate Them, 2005:
[See PDF for image]
Source: GAO analysis of relevant statutes, regulations, and guidance.
[A] HRSA defines a rational service area for the delivery of primary
medical care services as (1) a county or group of contiguous counties
whose population centers are within 30 minutes travel time of each
other; (2) a portion of a county, or an area made up of portions of
more than one county, whose population, because of topography, market
or transportation patterns, distinctive population characteristics, or
other factors has limited access to contiguous area resources, as
measured generally by a travel time greater than 30 minutes to such
resources; or (3) established neighborhoods and communities within
metropolitan areas that display a strong self- identity (as indicated
by a homogeneous socioeconomic or demographic structure or a tradition
of interaction or interdependency), have limited interaction with
contiguous areas, and that, in general, have a minimum population of
20,000. 42 C.F.R. pt. 5, app. A, I B.1, II A.1.(a) (2005).
[B] Special circumstances exist in an area if it has unusually high
needs for primary care services or an insufficient supply of primary
care providers. Unusually high needs may be demonstrated if, for
example, more than 20 percent of the population have incomes below the
federal poverty level. Insufficient supply of providers may be
demonstrated if, for example, the area has unusually long waits for
appointments for routine medical services and at least two-thirds of
the area's physicians do not accept new patients. 42 C.F.R. pt. 5, app.
A, I B.4., 5 (2005).
[End of figure]
Since 2002, two kinds of facilities--(1) health centers and (2) rural
health clinics that certify that they treat everyone regardless of
ability to pay--have been automatically designated as facility HPSAs
without going through the standard request and review process.[Footnote
14] Health centers include consolidated health centers, health center
look-alikes, and tribal health centers:[Footnote 15]
² Consolidated Health Centers: These health centers--which include
community health centers, migrant health centers, health centers for
the homeless, and health centers for residents of public housing--
receive grants and grant funding[Footnote 16] under section 330 of the
Public Health Service Act. Consolidated health centers provide
comprehensive community-based primary care services to individuals
regardless of their ability to pay and are required to serve the
medically underserved.[Footnote 17]
² Health center look-alikes: These facilities have been determined to
meet all of the requirements necessary to receive a grant under section
330 of the Public Health Service Act but do not receive such funding.
² Tribal health centers: These facilities receive federal support to
provide outpatient health services and are operated by tribes, tribal
organizations, or urban Indian organizations under the Indian Self-
Determination Act or the Indian Health Care Improvement Act.
Rural health clinics are located in rural areas and can operate either
independently or as part of a larger organization, such as a hospital,
skilled nursing facility, or home health agency.[Footnote 18] Unlike
health centers, which are public or private nonprofit facilities, rural
health clinics may function as for-profit entities. Rural health
clinics must offer primarily outpatient primary medical care, but
unlike health centers, they are not required to serve all individuals
regardless of their ability to pay. Therefore, those rural health
clinics that wish to receive automatic facility HPSA designation must
certify to HRSA that they provide services to all individuals,
regardless of their ability to pay, in order to receive the
designation.
After receiving the HPSA designation, each geographic, population-
group, and facility HPSA is scored on a scale of 0 to 25, with higher
scores indicating greater relative need for primary care providers. The
HPSA score is based on four elements, including elements used for HPSA
designation: the ratio of population to primary care physicians (1 to 5
possible points, then doubled), poverty rate (0 to 5 possible points),
infant mortality rate or low birth weight rate (0 to 5 possible
points), and travel time or distance to the nearest available source of
primary care (0 to 5 possible points). For a health center or rural
health clinic automatically designated as a facility HPSA, if complete
data are not available or HRSA cannot match the facility to appropriate
data to calculate a HPSA score, the HPSA receives either a score of 0
or a partial score based on the sum of factors for which data are
obtainable.[Footnote 19] According to HRSA's data on health centers and
rural health clinics that received automatic designation as facility
HPSAs, 10 percent of these facility HPSAs had a HPSA score of 0 as of
September 2005.
HRSA calculates the HPSA score using the information from the HPSA
designation request. For health centers and rural health clinics that
receive automatic facility HPSA designation, HRSA calculates the HPSA
score using nationally available data and approximates the service area
of a health center or rural health clinic by using data on the Primary
Care Service Area in which the facility is located.[Footnote 20] Any
automatically designated facility HPSA located in a geographic or
population-group HPSA may instead use the HPSA score for that
geographic area or population group, which, according to HRSA
officials, is likely to be much higher than the automatic facility HPSA
score.[Footnote 21] According to HRSA officials, nationally available
data used for automatic facility HPSA scores are often not as current
or as precise as data collected for individual geographic and
population-group HPSA designations.
HHS is required by law to review HPSA designations annually to
determine if the designations remain appropriate in light of the
applicable requirements.[Footnote 22] Each year, it must also publish a
list of designated HPSAs in the Federal Register.[Footnote 23] For
HPSAs designated through the standard request and review process, HHS
reviews the designations by giving a list of HPSAs that have been
designated for 3 full years to each state and asking the relevant state
groups--including the state's governor's office and state health
department--to update the information. HPSA designations for which data
are not provided or that no longer meet the designation criteria are
proposed for withdrawal. A HPSA that is proposed for withdrawal remains
designated as a HPSA until HHS publishes in the Federal Register either
a notification that the HPSA designation has been withdrawn or an
updated list of designated HPSAs that does not include that
HPSA.[Footnote 24] Before a HPSA designation can be withdrawn, however,
interested parties and groups must be allowed to provide data and
information in support of the designation. A health center or rural
health clinic receiving automatic facility HPSA designation must
demonstrate every 6 years after receiving its automatic designation
that it meets the definition of a HPSA.[Footnote 25]
HPSAs Are Located in Every State and Are Used by Multiple Federal
Programs:
More than 5,500 HPSAs were located throughout the country as of
September 2005. We estimated that over half of these HPSAs were
geographic or population-group HPSAs; the rest were facility HPSAs.
Numerous federal programs have used these HPSA designations to allocate
their programs' resources or provide benefits, which is an incentive
for obtaining and retaining the HPSA designation.
Number and Location of HPSAs:
Using HRSA data, we identified 5,594 designated HPSAs as of September
2005. We estimated that slightly more than half (3,032) of these HPSAs
were designated for geographic areas or population groups. HRSA
calculated that geographic and population-group HPSAs needed 6,941
additional full-time primary care physicians to achieve ratios of
population to primary care physicians that would remove the HPSA
designations (see table 1).
Table 1: Number of, Population in, and Physicians Needed in Geographic
and Population-Group HPSAs, September 2005:
HPSA type: Geographic area;
Number of HPSAs: 1,646;
Population in HPSAs[A]: 34,821,125;
Primary care physicians needed[B]: 3,549.
HPSA type: Population group;
Number of HPSAs: 1,386;
Population in HPSAs[A]: 24,912,956;
Primary care physicians needed[B]: 3,392.
HPSA type: Total;
Number of HPSAs: 3,032;
Population in HPSAs[A]: 59,734,081;
Primary care physicians needed[B]: 6,941.
Source: HRSA.
[A] These numbers represent the resident civilian population of the
related HPSA. For example, for geographic HPSAs that consist of an
entire county, this number reflects the resident civilian population of
the entire county. For population-group HPSAs, this number reflects
that groups' population within particular geographic areas.
[B] The number of additional full-time-equivalent primary care
physicians required to achieve population-to-primary care physician
ratios of 3,500:1 (less than 3,500:1 but greater than 3,000:1 under
special circumstances), which are needed to remove the HPSA
designations.
[End of table]
Of the 1,646 geographic HPSAs, slightly more than half (831) consisted
of an entire county, and the remainder (815) consisted of other service
areas within counties, such as specific census tracts. As illustrated
in figure 3, geographic and population-group HPSAs designated as of
January 2006 were located in 2,494 counties in all 50 states and the
District of Columbia.[Footnote 26]
Figure 3: U.S. Counties with Geographic and Population-Group HPSAs,
January 2006:
[See PDF for image]
Sources: GAO analysis of HRSA and U.S. Census Bureau data and
MapInfo(map).
Note: Counties that contained both geographic and population- group
HPSAs are shown as geographic HPSAs. We identified 218 counties that
included both geographic and population-group HPSAs as of January 2006.
[End of figure]
We estimated that slightly less than half (2,562) of all HPSAs
designated as of September 2005 were facility HPSAs. Of these, about 63
percent (1,625) were health centers,[Footnote 27] about 23 percent
(590) were rural health clinics, and about 14 percent (347) were
federal or state correctional institutions (see fig. 4). Excluded from
this count of facility HPSAs were 136 public or nonprofit medical
facilities that HRSA's data indicated had requested and received a
facility HPSA designation, but that HRSA officials said could be
duplicates of health centers that HRSA's data showed as having
automatically received a facility HPSA designation. Also excluded were
21 health centers that HRSA's data identified as health centers for
Alaska Natives that received automatic facility HPSA designations, but
that HRSA and IHS officials said could be duplicates of health centers
HRSA's data identified as tribal health centers.
Figure 4: Types of Facility HPSAs, September 2005:
[See PDF for image]
Source: GAO analysis of HRSA data.
Note: Percentages of health center subtypes do not add to 63 percent
because of rounding.
[End of figure]
As of September 2005, health centers with facility HPSA designations
were located in all 50 states and the District of Columbia.[Footnote
28] Rural health clinics with facility HPSA designations were located
in 41 states, and federal or state correctional institutions with
facility HPSA designations were located in 46 states.[Footnote 29]
Federal Programs Using HPSA Designations:
Although the HPSA designation system was originally used to designate
areas for placement of providers through NHSC programs, the HPSA
designation, and in some cases the HPSA score, have since been used by
more than 30 federal programs to allocate resources or provide
benefits. In fiscal year 2005, NHSC--which received $131 million in
funding from HRSA appropriations--administered four programs that used
the HPSA designation--three of which also used the HPSA score:[Footnote
30]
² NHSC Scholarship Program: NHSC awards scholarships to health
professions students who agree to practice for at least 2 years in a
HPSA after completing training as a primary care physician, nurse
practitioner, nurse-midwife, physician assistant, or other eligible
provider.[Footnote 31] Scholarship recipients are limited to practicing
at NHSC-approved practice sites in HPSAs with high need, as determined
by the HPSA designation score.[Footnote 32] For the period July 1,
2005, through June 30, 2006, scholarship recipients completing training
who were primary care physicians were required to practice in HPSAs
with scores of 14 or higher, while those completing training as nurse
practitioners, physician assistants, and nurse-midwives were required
to practice in HPSAs with scores of at least 13, 13, and 8,
respectively.[Footnote 33] At the end of fiscal year 2005, about 670
NHSC scholarship recipients, including primary care physicians, nurse
practitioners, nurse-midwives, and physician assistants, were
practicing in HPSAs to complete their NHSC service
obligations.[Footnote 34]
² NHSC Loan Repayment Program: NHSC repays educational loans of fully
trained health professionals who agree to practice for at least 2 years
in a HPSA.[Footnote 35] In addition to the practice sites approved for
scholarship recipients, loan repayment recipients--including primary
care physicians, nurse practitioners, physician assistants, nurse-
midwives, and other providers--may practice at NHSC-approved sites in
other HPSAs, including those with lower HPSA scores. Loan repayment
awards are made to providers who practice in higher-scoring HPSAs
first, and then to providers who practice in lower-scoring HPSAs in
descending order as long as program funds are available. Sufficient
funds were available for fiscal years 2003 through 2005 to make awards
to all providers with eligible and complete loan repayment
applications, regardless of the practice location's HPSA score. At the
end of fiscal year 2005, about 1,700 NHSC loan repayment recipients
were practicing in HPSAs to complete their NHSC service obligations.
² NHSC State Loan Repayment Program: NHSC provides grants to states to
operate state loan repayment programs.[Footnote 36] Eligibility
requirements and benefits, such as the maximum amount of loan repayment
each year, may vary from state to state, but state loan repayment
recipients must agree to provide primary health services in a HPSA. At
the end of fiscal year 2005, about 680 NHSC state loan repayment
recipients were practicing in HPSAs under this program.
² NHSC Ready Responder Program: Providers--including primary care
physicians, nurse practitioners, physician assistants, and nurses--can
receive salaries, benefits, and moving expenses to serve as
commissioned officers in the U.S. Public Health Service who are
assigned by NHSC to practice for 3 years in the neediest
HPSAs.[Footnote 37] In determining practice locations for Ready
Responders, NHSC gives preference to NHSC-approved sites in HPSAs with
high scores. HRSA's 2004 notice to recruit providers to participate in
this program stated that NHSC Ready Responders would be part of a
mobile team of health professionals who, in addition to the services
they provide to patients at their assigned sites, might be called upon
to respond to regional or national emergencies. At the end of fiscal
year 2005, 56 NHSC Ready Responders were practicing in HPSAs.
In addition to the 4 NHSC programs, more than 26 other federal programs
have used the HPSA designation to allocate resources or provide
benefits.[Footnote 38] For example:
² CMS's Medicare Incentive Payment program pays physicians a 10 percent
bonus for services provided to Medicare beneficiaries in a geographic
HPSA.[Footnote 39] According to CMS's Office of Financial Management,
the Medicare program paid about $148 million in these bonus payments in
fiscal year 2005.
² CMS's Rural Health Clinic program employs special payment rules for
the reimbursement of services provided by rural health clinics under
Medicare and Medicaid, which is an incentive for becoming a rural
health clinic. For example, rural health clinics are reimbursed under a
modified cost-based method of payment under Medicare. For reimbursement
purposes, a rural health clinic must be located in a geographic or
population-group HPSA in a rural area, a rural area designated by a
state's governor (or chief executive officer) and certified by HHS as
an area with a shortage of personal health services, or a rural area
HRSA has designated as a medically underserved area (MUA).[Footnote 40]
² Federal agencies--including HHS, the Appalachian Regional
Commission,[Footnote 41] and the Delta Regional Authority[Footnote 42]-
-as well as state health departments, operate programs, called J-1 visa
waiver programs, to attract foreign physicians who have just completed
their graduate medical education in the United States to practice in
underserved areas. In exchange for a commitment to practice for at
least 3 years at a facility located in, or treating residents of, a
HPSA, an MUA, or a medically underserved population (MUP), foreign
physicians can receive the benefit of a waiver of a 2-year foreign
residence requirement.[Footnote 43] Of the federal agencies
administering J-1 visa waiver programs in 2005, HHS required foreign
physicians receiving J-1 visa waivers through its J-1 visa waiver
program to practice in certain health centers, rural health clinics, or
other facilities in HPSAs with a HPSA score of 14 or higher.[Footnote
44]
² More than 15 federal programs that funded health professions
education and training grants in fiscal year 2005 used the HPSA
designation to provide funding preferences to grant
applicants.[Footnote 45] Authorized under title VII of the Public
Health Service Act--with more than $160 million in funding from HRSA's
fiscal year 2005 appropriations--these programs provided funding
preferences to grant applicants, such as health professions schools
that placed a high or increasing number of graduates in settings
serving medically underserved communities, including HPSAs. For
purposes of the funding preference, the Public Health Service Act
defines medically underserved communities to include areas or
populations that are eligible for HPSA designation, or that meet other
criteria, such as being eligible to be served by a community or migrant
health center.[Footnote 46]
The use of the HPSA designation by more than 30 federal programs to
allocate resources or provide benefits is an incentive for obtaining
and retaining a HPSA designation, even if the HPSA does not want or
need additional primary care providers. Agencies or individuals
requesting initial designations or continuations of the HPSA
designations for geographic areas, population groups, or facilities may
instead want the designation for other purposes, for example, to be
eligible for benefits such as the 10 percent bonus payment for
physician services under CMS's Medicare Incentive Payment program. In
1998, COGME reported that one possible reason that the number of HPSAs
had not declined was that "as the penalty for designation loss has
increased, organizations have become more adept at making the case for
retaining or attaining this coveted status."[Footnote 47]
Research Points to Shortcomings with Designation Methodology:
Of the reports published since 1995 that addressed the criteria or
methodology used to designate HPSAs, we identified one that supported
one key element of the criteria and six that pointed to shortcomings in
the designation methodology. These six reports were consistent with
what we reported in 1995. HHS officials have acknowledged these
shortcomings and the department has been working on a proposal for
revising the HPSA designation system since 1998, which, as of September
2006, had not been finalized. Another problem we identified in 1995
that persists in 2006 is HRSA's lack of timely removal of HPSA
designations that no longer meet the designation criteria.
Of the seven reports we identified as research on the HPSA criteria or
methodology, one of the peer-reviewed reports addressed the
relationship between one key element of the HPSA designation criteria
and primary care physician supply. This report found a positive
association between primary care physician supply and an area's income-
-one of the elements of the HPSA criteria used to demonstrate unusually
high needs for primary care services. Specifically, the researchers
found that areas with higher incomes had a greater number of primary
care physicians than areas with lower incomes.[Footnote 48]
Other published reports have, however, pointed to shortcomings in the
methodology HRSA uses to designate HPSAs--specifically that the system
has not effectively identified areas with primary care shortages or
helped target federal resources to benefit those who are
underserved.[Footnote 49] For example, reports--including one we issued
in 1995--have noted that HRSA's designation methodology does not
accurately identify those providers available to furnish primary health
care services.[Footnote 50] As a result, the HPSA methodology can
overstate the need for additional primary care providers, limiting the
usefulness of the HPSA designation system as a screen to identify which
communities should be eligible for additional program benefits. Since
1995, we and others have reported problems with HRSA's exclusion of
several categories of primary care providers when calculating the
available primary care providers. For example, in our 1995 report, we
estimated that the reported need for additional providers in 1994 would
have been reduced by up to 50 percent if certain categories of primary
care physicians and nonphysician providers--which were excluded by
HRSA--had been included in the HPSA calculations.[Footnote 51] In
total, we estimated that 2,539 primary care physicians already
providing services in shortage areas (including NHSC physicians and
foreign physicians with J-1 visa waivers) and other categories of
providers who deliver primary care services in HPSAs (including
physician assistants and nurse-midwives) were excluded by HRSA in 1994.
Reports have also concluded that some of the geographic areas that HRSA
evaluates for designation--that is, those based on county boundaries--
may not always provide a realistic reflection of an area's health care
needs. For these HPSA designation requests, measuring the availability
of primary care physicians only in the county where individuals live
may underestimate certain residents' access to medical care.[Footnote
52] For example, two reports we identified discussed the likelihood of
people crossing county lines to obtain health care services when these
services were not available in their community.[Footnote 53] In one
report, researchers evaluated the relationship between health status
and medical care resources and found that individuals aged 64 years or
younger living in nonmetropolitan areas reported better health when
there was greater physician supply in the county where they lived and
adjoining counties. According to these researchers, the results
suggested that younger individuals in nonmetropolitan areas were
willing and able to cross county lines to obtain health care.[Footnote
54]
Researchers have also noted that the HPSA designation methodology
favors those states or areas that have experience in completing and
submitting a HPSA designation request.[Footnote 55] One team of
researchers reported that officials in certain states and localities
were effective in identifying areas that would qualify for a HPSA
designation and in providing timely and appropriate data for the
request, whereas other areas were unable to navigate the process as
effectively. The researchers observed that certain areas were more
likely to have HPSA designations than others--independent of the actual
local situation.[Footnote 56]
Recognizing the shortcomings in the HPSA designation system identified
by available research and our prior work, HHS has been working on a
proposal for a revised designation system since 1998. According to HRSA
officials, the proposal incorporates factors to account for all primary
care providers in an area--including foreign physicians with J-1 visa
waivers, NHSC physicians, and nurse practitioners and physician
assistants--and includes the creation of a master database to house
national data relevant to HPSA criteria. As of September 2006, this
proposal was in the department's clearance process.
Another problem we identified in 1995, that remains a problem in 2006,
is that HRSA does not review designated HPSAs and subsequently remove
the designation of those areas, population groups, or facilities that
no longer meet the HPSA criteria in a timely manner. While we did not
audit HRSA's process for periodically reviewing HPSAs, in August 2005,
the HHS Office of Inspector General reported that as of 2003, HRSA had
not conducted timely reviews of HPSA designations.[Footnote 57] In the
agency's comments that were included in the August 2005 report, HRSA
acknowledged this problem, stating that the agency was unable to
complete the review of designated HPSAs for continued eligibility in
less than 3 years because of resource limitations. As of September
2006, we found that although HHS is required to publish a list of
designated HPSAs in the Federal Register by July 1 of each year--
thereby removing the designation of any HPSAs that were proposed for
withdrawal that are not published--the department has not done so since
February 2002.[Footnote 58] HRSA officials told us in June 2006 that
the department has not published a list of HPSAs in the Federal
Register for more than 4 years because of difficulties with computer
programming, but the agency hoped to resolve those issues and to
forward an updated list for publication by fall 2006.[Footnote 59]
Meanwhile, those HPSAs that were proposed for withdrawal because they
no longer meet the HPSA criteria have retained their HPSA
designation.[Footnote 60] As a result, federal programs that use the
HPSA designation, such as the Medicare Incentive Payment program or
HRSA's health professions education and training programs, may have
been allocating resources or providing benefits to areas, population
groups, or facilities that no longer meet the HPSA criteria.
Many Health Centers and Rural Health Clinics Did Not Benefit from
Automatic HPSA Designation:
Many health centers and rural health clinics did not benefit from
automatic designation as facility HPSAs because they were located in
geographic or population-group HPSAs. Most health centers also received
a HPSA score associated with the automatic designation that was too low
to qualify them for programs that required a minimum HPSA score in
2005, although they qualified for programs that did not have such a
requirement. Of the relatively few rural health clinics that chose to
certify that they would treat anyone regardless of ability to pay and,
as a result, received the automatic designation as facility HPSAs, most
also received scores too low to qualify for benefits from certain
programs that required a higher HPSA score.
Relatively Few Health Centers Had HPSA Scores High Enough to Obtain
Providers through Certain Federal Programs:
For health centers that were located in a geographic or population-
group HPSA, automatic designation as a facility HPSA provided no
benefit unless the HPSA score associated with automatic designation was
higher than the score for the geographic or population-group HPSA in
which they were located. According to the National Association of
Community Health Centers, health centers had advocated for automatic
HPSA designation because it would allow those not located in geographic
or population-group HPSAs to be eligible for providers from NHSC.
Although limitations in HRSA's data prevented us from measuring the
precise impact of the automatic HPSA designation on health centers,
HRSA officials estimated that about half of the health centers that
received automatic designation as a facility HPSA in 2002 were located
in a geographic or population-group HPSA and therefore did not receive
this benefit.
As of September 2005, 73 (less than 5 percent) of the 1,625 health
centers that had received automatic designation as facility HPSAs had
an associated HPSA score high enough to qualify for a physician through
the NHSC Scholarship Program or HHS's J-1 visa waiver program.[Footnote
61] These health centers received a HPSA score of 14 or higher--the
HPSA score required by these programs for physician placement (see fig.
5). Eighty-six (about 5 percent) of the 1,625 health centers with
automatic facility HPSA designation received a HPSA score of 13 or
higher--the HPSA score required by the NHSC Scholarship Program to
qualify for placement of a nurse practitioner or physician assistant.
Figure 5: Distribution of HPSA Scores among Health Centers
Automatically Designated as Facility HPSAs, September 2005:
[See PDF for image]
Source: GAO analysis of HRSA data.
Notes: This figure includes scores for 1,624 of the 1,625 health
centers that, as of September 2005, received a HPSA score as part of
automatic designation as a facility HPSA. One tribal health center had
not received a HPSA score from HRSA as of September 2005. Health
centers that automatically received facility HPSA designation include
those that received grants under the consolidated health center
program, health center look-alikes, and tribal health centers.
[A] For assignment of NHSC providers through the NHSC Scholarship
Program for the period July 1, 2005, through June 30, 2006, a HPSA
score of 14 or higher was required to be eligible for a physician; a
score of 13 or higher was required for a nurse practitioner or
physician assistant; and a score of 8 or higher was required for a
nurse-midwife. HHS's J-1 visa waiver program required a HPSA score of
14 or higher for all of 2005.
[B] The maximum HPSA score a health center can receive is 25.
[End of figure]
In contrast, automatic facility HPSA designation made health centers
eligible, regardless of HPSA score, to apply in 2005 for a physician or
other health care provider through the NHSC Loan Repayment
Program.[Footnote 62] According to an official with the National
Association of Community Health Centers, health center officials were
pleased with this benefit but also viewed it with caution because NHSC
loan repayment awards are made first to providers who agree to practice
in higher-scoring HPSAs and then to providers who agree to practice in
lower-scoring HPSAs, in decreasing order of HPSA score. Although NHSC
had sufficient funding for all qualifying loan repayment applicants
from 2003 through 2005, health center officials were concerned that in
future years, NHSC funding may be insufficient to sustain this benefit
for health centers with relatively low HPSA scores.
Few Rural Health Clinics Have Received Automatic HPSA Designation as
Facility HPSAs:
As of September 2005, 590 (16 percent) of the 3,637 rural health
clinics in the United States had received automatic designation as
facility HPSAs. To receive automatic designation, rural health clinics,
unlike health centers, must certify that they provide health care
services regardless of an individual's ability to pay. To qualify for
automatic HPSA designation, some rural health clinics--including those
that are for-profit entities--would have to restructure their billing
practices, and according to officials at the National Association of
Rural Health Clinics and HRSA's Office of Rural Health Policy, it may
not be in their interest to do so.
As with health centers, the main benefit cited by officials at the
Office of Rural Health Policy of automatic HPSA designation for rural
health clinics is to be eligible for NHSC physicians or other primary
care providers. Rural health clinics that were located in geographic or
population-group HPSAs would not benefit from automatic designation
unless the associated HPSA score was higher than the score for the
geographic or population-group HPSAs in which they were located. Data
were not available to determine how many of the 590 rural health
clinics with automatic facility HPSA designations were located in
geographic or population-group HPSAs before the 2002 provision was
implemented. An official at the National Association of Rural Health
Clinics reported, however, that a recent study estimated that over 70
percent of all rural health clinics--including those that did not
receive the automatic facility HPSA designation--were located in
geographic HPSAs before 2002 and were therefore already eligible for
federal programs requiring HPSA designation.[Footnote 63]
As of September 2005, less than 1 percent of the 590 rural health
clinics that had received automatic designation as facility HPSAs had
associated HPSA scores of 14 or higher needed to qualify for a
physician through the NHSC Scholarship Program or HHS's J-1 visa waiver
program (see fig. 6).[Footnote 64] About 1 percent received a HPSA
score of 13 or higher--the HPSA score required by the NHSC Scholarship
Program to qualify for a nurse practitioner or physician assistant.
Like health centers with lower HPSA scores, rural health clinics
automatically designated as facility HPSAs but scoring lower than 14
could recruit a physician or other provider through the NHSC Loan
Repayment Program.[Footnote 65]
Figure 6: Distribution of HPSA Scores among Rural Health Clinics
Automatically Designated as Facility HPSAs, September 2005:
[See PDF for image]
Source: GAO analysis of HRSA data.
Notes: This figure includes scores for 583 of the 590 rural health
clinics that, as of September 2005, received a HPSA score as part of
automatic designation as a facility HPSA. Seven rural health clinics
that received the automatic HPSA designation had not received a HPSA
score from HRSA as of September 2005.
[A] For assignment of NHSC providers through the NHSC Scholarship
Program for the period July 1, 2005, through June 30, 2006, a HPSA
score of 14 or higher was required to be eligible for a physician; a
score of 13 or higher was required for a nurse practitioner or
physician assistant; and a score of 8 or higher was required for a
nurse-midwife. HHS's J-1 visa waiver program required a HPSA score of
14 or higher for all of 2005.
[B] The maximum HPSA score a rural health clinic can receive is 25.
[End of figure]
Conclusions:
Many federal programs continue to rely on HPSA designations to allocate
federal resources or provide benefits, even though shortcomings we and
others have reported since 1995 have not been addressed. In particular,
the omission of important categories of primary care providers--such as
foreign physicians with J-1 visa waivers and nonphysician primary care
providers--from calculations for HPSA designation can overstate the
need for additional primary care providers. Although HHS has recognized
the need for improvements and has been working since 1998 on a proposal
to revise the HPSA designation system, it remains to be seen when HHS
will make such improvements and what changes will be made. In addition,
HRSA has not regularly removed the HPSA designation of those areas,
population groups, or facilities that no longer meet the designation
criteria.
Available information suggests that the provision to automatically
designate health centers and certain rural health clinics as facility
HPSAs has benefited a relatively small number of these facilities. The
precise impact of the provision could not be measured, however, because
of limitations with available HHS data. For example, the available data
did not include sufficient geographic information to determine which of
these facilities were located in geographic or population-group HPSAs
before receiving automatic designation as facility HPSAs.
Recommendations for Executive Action:
We recommend that the Secretary of Health and Human Services take the
following two actions: (1) publish a list of designated HPSAs in the
Federal Register or otherwise remove, through Federal Register
notification, the HPSA designations for those HPSAs that no longer meet
the criteria or have not provided updated data in support of their
designations and (2) complete and publish HHS's proposal to revise the
HPSA designation system and address the shortcomings that have been
identified in the current methodology for designating HPSAs.
Agency Comments:
We received comments on a draft of this report from HHS (see app. V).
The department generally agreed with our findings and concurred with
both recommendations. Specifically, the department agreed that a more
timely publication of the Federal Register listing of designated HPSAs
is necessary to ensure that only those areas meeting the regulations
remain designated, and stated that HRSA should publish lists of HPSAs
or HPSA withdrawals to ensure that designations that have already been
proposed for withdrawal are actually withdrawn. The department also
noted that it is proposing a change in the process for withdrawing HPSA
designations, but it did not provide any details on this proposal. HHS
also agreed with our recommendation that the department complete and
publish its proposal to revise the HPSA designation system. HHS stated
that this proposal would address shortcomings that we identified in
this and previous reports and would also affect the regulations
governing MUA and MUP designations.
HHS also commented on our finding that many health centers and rural
health clinics did not benefit from automatic designation as facility
HPSAs. Specifically, HHS stated that our draft report provided a
somewhat misleading assessment of the impact of the automatic
designation process and the department provided additional information
on NHSC placements in automatically designated HPSAs in 2005. Our draft
report stated that few health centers had HPSA scores associated with
automatic designation that were high enough to qualify for a physician
through the NHSC Scholarship Program, but that all health centers that
received automatic designation as HPSAs, even those with lower HPSA
scores, could apply in 2005 for a health care provider through the NHSC
Loan Repayment Program. The data the department provided on NHSC
placements in automatically designated health centers were actually
consistent with the statement in our draft report. HHS's data, which
HHS officials said included both primary care and nonprimary care
providers, showed that of 216 NHSC providers placed in health centers,
relatively few (less than 5 percent) were placed through the NHSC
Scholarship Program and the NHSC Ready Responder Program (less than 1
percent), whereas the vast majority (more than 95 percent) were placed
through the NHSC Loan Repayment Program. According to HRSA officials,
data for primary care provider placements (which were not included in
the department's comments), showed a similar distribution between the
three NHSC programs for 155 primary care NHSC placements in health
centers in 2005. In its comments, HHS also provided information on the
process for scoring automatically designated HPSAs and on NHSC and J-1
visa waiver programs. In response, we added information on J-1 visa
waiver programs administered by federal agencies other than HHS and by
state health departments.
Finally, HHS suggested that we clarify that our scope was limited to
primary care HPSAs. We made revisions to the report to highlight that
our review only examined primary care HPSA designations.
The department also provided technical comments, which we incorporated
as appropriate.
We are sending copies of this report to the Secretary of Health and
Human Services, the Administrator of HRSA, the Administrator of CMS,
and to appropriate congressional committees. We will also provide
copies to others upon request. In addition, the report will be
available at no charge on the GAO Web site at [Hyperlink,
http://www.gao.gov].
If you or your staff members have any questions about this report,
please contact me at (312) 220-7600 or aronovitzl@gao.gov. Contact
points for our Offices of Congressional Relations and Public Affairs
may be found on the last page of this report. GAO staff members who
made contributions to this report are listed in appendix VI.
Signed by:
Leslie G. Aronovitz:
Director, Health Care:
[End of section]
Appendix I: Scoring of Health Professional Shortage Areas:
Each designated health professional shortage area (HPSA) receives a
score that the Department of Health and Human Services's (HHS) Health
Resources and Services Administration (HRSA) uses to rank its shortage
of primary care providers, or need, relative to other HPSAs. The HPSA
score is used by some federal programs, such as the National Health
Service Corps (NHSC) Scholarship Program, which requires participants
to practice in locations with higher HPSA scores. The scores, ranging
from 0 to 25, are based on four factors, for which each HPSA is given a
certain number of points (see fig. 7). To calculate a HPSA score,
points for the population-to-primary care physician ratio, ranging from
1 to 5 points, are doubled and then summed with the points for each of
the other three factors. For health centers and rural health clinics
receiving automatic designation as facility HPSAs, if complete data are
not available, or if HRSA cannot match the facility to appropriate data
to calculate a HPSA score, the HPSA receives either a score of 0 or a
partial score based on the sum of factors for which data are
obtainable.
Figure 7: Scoring of HPSAs, 2005:
[See PDF for image]
Source: HRSA.
[A] For HPSA designation and scoring, HRSA counts nonfederal physicians
who practice principally in one of the primary care specialties of
general or family practice, general internal medicine, pediatrics, or
obstetrics and gynecology. HRSA does not count federal physicians;
physicians with NHSC or J-1 visa waiver obligations; or physicians
engaged solely in administration, research, or teaching. See HRSA,
Bureau of Health Professions, "Health Professional Shortage Area
Guidelines for Primary Medical Care/Dental Designation,"
http://bhpr.hrsa.gov/shortage/hpsaguidepc.htm (downloaded Nov. 14,
2005).
[B] HHS's poverty guidelines for 2005 set the poverty level for a
family of four at an annual income of $19,350 in the 48 contiguous
states and the District of Columbia ($24,190 in Alaska and $22,260 in
Hawaii). Poverty guidelines are not defined for American Samoa, the
Commonwealth of the Northern Mariana Islands, the Federated States of
Micronesia, Guam, Puerto Rico, the Republic of the Marshall Islands,
the Republic of Palau, and the U.S. Virgin Islands; offices
administering federal programs may decide whether to use the guidelines
for the 48 contiguous states and the District of Columbia for those
jurisdictions or some other procedure. 70 Fed. Reg. 8373-75 (Feb. 18,
2005).
[C] Infant mortality rate is defined as the number of infant deaths per
1,000 live births. Low birth weight rate is defined as the percentage
of live births below 2,500 grams (5 pounds, 8 ounces).
[End of figure]
[End of section]
Appendix II: Medically Underserved Area or Population Designations and
Medically Underserved Community Definition:
Medically underserved areas (MUA) and medically underserved populations
(MUP) generally are areas, or populations within areas, that are
designated by HHS's HRSA as having a shortage of health care services.
The MUA and MUP designations were developed about the same time as the
HPSA designation system but independently from it. Authorized by the
Health Maintenance Organization Act of 1973, MUA and MUP designations
have been used for identifying areas eligible to participate in the
consolidated health center program. That is, in order to receive health
center grant funding as a community health center, migrant health
center, or a center serving residents of public housing or the
homeless, the health center must be located in or serve the residents
of an MUA or MUP.
MUAs are designated for the entire population of a particular
geographic area. MUP designations are limited to particular groups of
underserved people within an area. Individual facilities are not
eligible for MUA or MUP designations as they are under the HPSA
designation system. As of September 2005, HRSA had designated 3,443
geographic areas as MUAs and 488 population groups as MUPs.
HRSA designates MUAs and MUPs on the basis of four factors of health
service need, the first three of which are also used for HPSA
designation or scoring:
² ratio of population to number of primary care physicians,
² infant mortality rate,
² percentage of the population with incomes below the federal poverty
level, and:
² percentage of population aged 65 or over.
To determine if an area meets the criteria to be designated as an MUA
or if a population within an area meets the criteria to be designated
as an MUP, each factor is assigned a weighted value, and these values
are summed to obtain a combined score.[Footnote 66] This score is used
to determine if an area or population can be designated as an MUA or
MUP. Areas and populations in the country are ranked using this score
to determine their order of need of health services. Areas and
populations with scores at or below 62 (the median score that was
calculated for all U.S. counties in 1975 for the four criteria) are
designated MUAs or MUPs. Those populations within areas with scores
above 62 may still be designated as MUPs if they demonstrate that
unusual local conditions impede access to or the availability of
personal health services. Such requests must be documented and
recommended by the state chief executive officer and the responsible
local officials.
One of the ways in which MUAs and MUPs differ from HPSAs is that MUA
and MUP designations are not required to be regularly updated.
According to a HRSA official, some areas with MUA or MUP designations
have not been reviewed since the 1980s. In 1998, HHS published a
proposal in the Federal Register to revise the MUA and MUP designations
and combine them with the HPSA designation system.[Footnote 67] The
department received over 800 comments on the proposal; subsequently,
HHS withdrew the proposal and began working on another one, which, as
of September 2006, was in the department's clearance process.
Another term--medically underserved community--is used to identify
underserved areas for purposes of funding preferences for health
professions education and training programs authorized under title VII
of the Public Health Service Act.[Footnote 68] A medically underserved
community is defined as an urban or rural area or population that:
² is eligible for HPSA designation;
² is eligible to be served by a community health center, migrant health
center, or a grantee serving residents of public housing or the
homeless;
² has a shortage of personal health services, as determined under
criteria issued by the Secretary of Health and Human Services under
section 1861(aa)(2) of the Social Security Act (relating to rural
health clinics); or:
² is designated by a state governor (in consultation with the medical
community) as a shortage area or medically underserved
community.[Footnote 69]
In fiscal year 2005, 15 programs authorized under title VII, with
funding of more than $160 million, provided funding preferences for any
qualified applicant, such as a health professions school, that had a
high rate for placing graduates in practice settings having the
principal focus of serving residents of medically underserved
communities or that achieved a significant increase in the rate of
placing graduates in such settings during the previous 2-year
period.[Footnote 70]
In addition, two nursing traineeship programs authorized under title
VIII of the Public Health Service Act used the medically underserved
community definition in providing a funding preference to grant
applicants. Title VIII provides a funding preference that includes
nursing workforce grant applicants with projects that will
substantially benefit rural or underserved populations.[Footnote 71]
For purposes of this statutory funding preference for two title VIII
programs--the Advanced Education Nursing Traineeship Program and Nurse
Anesthetist Traineeship Program--HHS used established clinical sites
identified under the definition of medically underserved community as
proxies for rural and underserved populations. In fiscal year 2005,
these two programs authorized under title VIII had about $17 million in
funding.
[End of section]
Appendix III: Scope and Methodology:
To conduct our work, we examined relevant laws, regulations, and HHS
documents related to the HPSA criteria and designation methodology that
were in effect in 2005 for primary care HPSAs, and reviewed our prior
work on the HPSA designation system.
To determine the number of HPSAs, we interviewed officials from HRSA,
who reported that precise, accurate, historical data on the total
number of HPSAs were not available. Therefore, we designed a
methodology that HRSA officials confirmed was reasonable for estimating
the number of HPSAs designated as of September 2005. We used the
following HRSA data sources for our methodology:
* For geographic and population-group HPSAs, we obtained and analyzed
summary statistics on HPSA designations as of September 2005 from the
Shortage Designation Branch within HRSA's Bureau of Health Professions.
* For facility HPSAs that were federal or state correctional
institutions and public or nonprofit medical facilities, we reviewed a
more detailed HRSA database of HPSAs designated as of September 2005,
downloaded from HRSA's Geospatial Data Warehouse.[Footnote 72]
* For facility HPSAs that were health centers and rural health clinics
with automatic facility HPSA designations, we analyzed HRSA's data
files of facilities with automatic HPSA designations as of September
2005.
We also analyzed HRSA data on the HPSA scores of health centers and
rural health clinics that received automatic HPSA designation to
determine which of these facilities qualified for federal programs that
required a minimum HPSA score as of September 2005. In addition, we
reviewed data as of January 2006 downloaded from HRSA's Geospatial Data
Warehouse to identify the locations of geographic and population-group
HPSAs and the HPSAs that were proposed to have their HPSA designations
withdrawn because they no longer met the criteria or did not provide
updated data in support of their designations.[Footnote 73]
We performed reliability checks on the HRSA data to identify potential
duplicate entries or inconsistencies in the data--for example,
inconsistencies between HRSA's published summary statistics and our
analysis summarizing the data from HRSA's Geospatial Data Warehouse--
and interviewed HRSA officials, Indian Health Service (IHS) officials,
and officials from associations representing health centers and rural
health clinics about the data. We accounted for limitations in the data
by excluding from our analysis the lists of two categories of facility
HPSAs--public or nonprofit medical facilities and Alaska Native health
centers--that HRSA officials stated could have been duplicates of
facilities in HRSA's data of health centers that received automatic
HPSA designation and that HRSA had not yet identified as duplicates and
removed from its data.[Footnote 74] In total, we excluded 136 public or
nonprofit medical facilities and 21 Alaska Native health centers. After
taking these steps, we determined that the data were sufficiently
reliable for our purposes.
To obtain information on HPSA designation and federal programs that use
HPSA designations, we reviewed Federal Register notices, laws,
regulations, and documents from HHS's Centers for Medicare & Medicaid
Services (CMS), HRSA, and IHS, including HRSA's National Health Service
Corps (NHSC) summaries of the NHSC programs' field strength at the end
of fiscal year 2005, and we reviewed our prior work on these
programs.[Footnote 75]
To identify available research on the criteria used to designate HPSAs
since we last reported on the criteria in 1995, we conducted a
literature search of articles, studies, and reports--which we call
reports--issued from January 1, 1995, through November 1, 2005. We
focused our review on the HPSA criteria that were in effect both in
2002 when the Health Care Safety Net Amendments were enacted and at the
time of our review. We performed the literature search of peer-reviewed
reports using the ProQuest search engine and keywords that were related
to the following key elements of the HPSA designation criteria,
including factors for determining areas with unusually high needs for
primary medical care services:[Footnote 76]
² ratio of population to primary care physicians,
² indicators of the population with incomes below the poverty level
(poverty or income),
² infant mortality rate,
² distance to health care services, and:
² birth rate.
We also identified reports published during that time frame related to
the HPSA criteria or methodology from the bibliographies of relevant
reports, recommendations from experts we interviewed, and our prior
work. We did not independently assess the methods used in the reports
we located.
Of the more than 340 reports located through the search, we identified
12 reports that we determined to be potentially relevant.[Footnote 77]
After reviewing these 12 reports, we found 1 report in a peer-reviewed
journal published from January 1, 1995, through November 1, 2005, that
addressed the relationship between one of the key elements of the HPSA
designation criteria (income) and primary care physician shortages or
supply. We selected this report because it met the following criteria,
in addition to the criteria outlined above:
² The report assessed the relationship between at least one key element
of the HPSA designation criteria and primary care physician shortages
or supply at the county, metropolitan statistical area, health service
area, or other local level.[Footnote 78]
² The report used a definition of primary care similar to the
definition used for the HPSA designation (e.g., general or family
practice, general internal medicine, pediatrics, and obstetrics and
gynecology).
Of the 12 reports reviewed, 6 reports discussed aspects of the
methodology used to designate HPSAs: 1 issued by the Council on
Graduate Medical Education (COGME), 1 issued by the Cecil G. Sheps
Center for Health Services Research at the University of North Carolina
at Chapel Hill, and 4 published in peer-reviewed journals.
To review the impact of the automatic designation on health centers and
rural health clinics as facility HPSAs, we analyzed HRSA's data on
automatic HPSA designations and their associated scores. We also
analyzed data on rural health clinics prepared by the Cecil G. Sheps
Center for Health Services Research at the University of North Carolina
at Chapel Hill for HRSA's Office of Rural Health Policy, which used
2003 and 2004 CMS data on rural health clinics and 2005 HRSA data on
HPSAs. However, limitations in these data prevented us from determining
exactly how many health centers and rural health clinics benefited when
all health centers and certain rural health clinics received automatic
designation as a result of the provision included in the Health Care
Safety Net Amendments of 2002. For example, the available data did not
include sufficient geographic information to determine which of these
facilities were located in geographic or population-group HPSAs before
receiving automatic designation as facility HPSAs. Because of the data
limitations, we also interviewed HHS officials in HRSA's Office of
Rural Health Policy and Bureau of Primary Health Care, as well as
officials from the National Association of Community Health Centers and
the National Association of Rural Health Clinics, to discuss the impact
of the automatic designation.
We performed our work from August 2005 through September 2006 in
accordance with generally accepted government auditing standards.
[End of section]
Appendix IV: Federal Programs Using Health Professional Shortage Area
and Other Designations of Underservice:
Various federal programs have used the HPSA, MUA, MUP or other
designations, such as medically underserved communities, to allocate
resources, such as scholarships or grants, or to provide benefits, such
as the waiver of requirements associated with a foreign physician's
visa (see table 2).
Table 2: Programs and Administering Agencies That Used HPSA, MUA, MUP
or Other Designations to Allocate Resources or Provide Benefits in
Fiscal Year 2005:
Program: Consolidated health center program;
Agency administering program or benefit: HRSA and CMS;
Resource allocated or benefit provided: Awards grants for operation of
health centers and other activities; provides benefits associated with
federally qualified health center status, including eligibility to
participate in a drug discount program and to receive reimbursement
from Medicare and Medicaid using special payment mechanisms, which
serve as an incentive for becoming a health center;
Federal funding information[A]: $1,734 million (funding from FY 2005
appropriations for HRSA)[B];
Designation(s) used by program: MUA; MUP.
Program: Federally qualified health center look-alike program;
Agency administering program or benefit: HRSA and CMS;
Resource allocated or benefit provided: Provides benefits associated
with federally qualified health center status, including eligibility to
participate in a drug discount program and to receive reimbursement
from Medicare and Medicaid using special payment mechanisms, which
serve as an incentive for becoming a health center;
Federal funding information[A]: [B];
Designation(s) used by program: MUA; MUP.
Program: Indian Health Scholarship Program;
Agency administering program or benefit: IHS;
Resource allocated or benefit provided: Awards American Indian and
Alaska Native students with scholarships for service in certain
practices in HPSAs or other practice locations authorized by
statute.[C];
Federal funding information[A]: $9 million (funding from FY 2005
appropriations for IHS);
Designation(s) used by program: HPSA[C].
Program: J-1 visa waivers for physicians at the request of federal
agencies (3 programs);
Agency administering program or benefit: Department of Homeland
Security's U.S. Citizenship and Immigration Services (USCIS),
Department of State, Appalachian Regional Commission, Delta Regional
Authority, HHS's Office of Global Health Affairs, and HRSA[D];
Resource allocated or benefit provided: Waives requirement for certain
foreign physicians to return to their home country or country of last
legal residence for 2 years after graduate medical education at the
request of an interested federal agency in exchange for at least 3
years of service in an area designated by the Secretary of Health and
Human Services as having a shortage of health professionals;
Federal funding information[A]: Not applicable;
Designation(s) used by program: HPSA[E]; MUA; MUP.
Program: J-1 visa waivers for physicians at the request of state health
departments (also known as the Conrad Program);
Agency administering program or benefit: USCIS, Department of State,
state health departments[D];
Resource allocated or benefit provided: Waives requirement for certain
foreign physicians to return to their home country or country of last
legal residence for 2 years after graduate medical education in
exchange for at least 3 years of service in an area designated by the
Secretary of Health and Human Services as having a shortage of health
professionals. Limited to 30 waivers per state per year. Up to five
waivers may be for physicians to practice outside of shortage areas as
long as they practice in a facility that serves patients residing in
such areas;
Federal funding information[A]: Not applicable;
Designation(s) used by program: HPSA:[F]Practice in a HPSA or treating
the residents of HPSAs; MUA: Practice in an MUA or treating the
residents of MUAs; MUP: Practice in an MUP or treating the residents of
MUPs.
Program: Medicare Incentive Payment program;
Agency administering program or benefit: CMS;
Resource allocated or benefit provided: Provides 10 percent bonus
payment on Medicare payments for physician services in geographic
HPSAs;
Federal funding information[A]: $148 million (FY 2005 Medicare
expenditures);
Designation(s) used by program: HPSA: Geographic HPSAs only.
Program: National Health Service Corps (4 programs)[G];
Agency administering program or benefit: HRSA;
Resource allocated or benefit provided: Awards scholarships to or
provides money to repay educational loans of students and health
professionals in exchange for at least 2 years of service in a HPSA;
supports commissioned officers of the U.S. Public Health Service to
serve for 3 years in the neediest HPSAs;
Federal funding information[A]: $131 million (funding from FY 2005
appropriations for HRSA);
Designation(s) used by program: HPSA.
Program: National Interest Waivers for Immigrant Physicians;
Agency administering program or benefit: USCIS;
Resource allocated or benefit provided: Waives the job offer
requirement placed on certain immigrants, including physicians who
agree to practice in a HPSA, an MUA, an MUP, or at Department of
Veterans Affairs facilities.[H];
Federal funding information[A]: Not applicable;
Designation(s) used by program: HPSA: Geographic HPSAs only; MUA.
Program: Rural Health Clinic program;
Agency administering program or benefit: CMS;
Resource allocated or benefit provided: Provides special Medicare and
Medicaid payment mechanisms for rural health clinics, which serve as an
incentive for becoming a rural health clinic;
Federal funding information[A]: $413 million (2004 Medicare
expenditures);[I] $333 Million (FY 2004 Medicaid expenditures)[I];
Designation(s) used by program: HPSA: Rural geographic and population-
group HPSAs only; MUA: Rural MUAs only; Other: Rural areas designated
by a state's governor as shortage areas.
Program: Scholarships for Disadvantaged Students Program;
Agency administering program or benefit: HRSA;
Resource allocated or benefit provided: Awards grants to health
professions schools to provide scholarships to full-time, financially
needy students from disadvantaged backgrounds enrolled in eligible
health professions or nursing programs. Funding priority is given to
schools applying for the funding based on the proportion of graduating
students going into primary care, the proportion of underrepresented
minority students, and the proportion of graduates working in medically
underserved communities.[J, K];
Federal funding information[A]: $47 million (funding from FY 2005
appropriations for HRSA);
Designation(s) used by program: HPSA; MUA; MUP; Other: Other medically
underserved communities[K].
Program: Title VII health professions education and training grant
programs[L] (16 programs);
Agency administering program or benefit: HRSA;
Resource allocated or benefit provided: Provides grants for health
professions education and training programs. Funding preference is
given to applicants that (1) place a high or increasing number of
graduates or program completers in settings having the principal focus
of serving medically underserved communities or (2) have 25 percent or
more of their graduates in full-time practice settings in medically
underserved communities and meet other statutory requirements.[K, M];
Federal funding information[A]: $165 million (funding from FY 2005
appropriations for HRSA);
Designation(s) used by program: HPSA; MUA; MUP; Other: Other medically
underserved communities[K].
Program: Title VIII nursing education programs[N] (2 Programs);
Agency administering program or benefit: HRSA;
Resource allocated or benefit provided: Provides grants to institutions
to provide financial support through traineeships for registered nurses
enrolled in advanced education nursing programs or in a master's degree
nurse anesthesia program. In awarding grants, a funding preference is
given to applicants whose projects will substantially benefit rural or
underserved populations, using sites identified under the definition of
medically underserved community as proxies, and gives special
consideration for applicants with students who have committed to
practicing in HPSAs after graduation.[K, O];
Federal funding information[A]: $17 million (funding from FY 2005
appropriations for HRSA);
Designation(s) used by program: HPSA; MUA; MUP; Other: Other medically
underserved communities[K].
Source: GAO analysis of HHS and other federal and state agency
information.
Note: In addition to the programs included in the table, other
programs, including rural health grant programs administered by HRSA,
have used the HPSA designation to some degree in allocating resources.
For example, in fiscal year 2005, HRSA's announcement for rural health
network development grants stated that a funding preference would be
given to those qualified applicants where the service area was located
in a designated HPSA, was a medically underserved community, or served
medically underserved populations. HRSA does not maintain a list of all
programs using the HPSA designation to allocate resources or provide
benefits.
[A] Funding amounts from HRSA and IHS reflect fiscal year 2005
appropriations or budget authority as reported in the agencies' fiscal
year 2006 budget justifications and provided by agency officials.
Budget authority is the authority provided by federal law to enter into
financial obligations that will result in future outlays involving
federal government funds. Budget authority includes appropriations and
also includes the authority to borrow, enter into contracts, or to
obligate and expend offsetting receipts and collections. Funding
amounts from CMS reflect expenditure amounts under the Medicare and
Medicaid programs from data in reports provided by CMS officials.
[B] According to CMS officials, although data on Medicare and Medicaid
payments to federally qualified health centers are available, data on
expenditures for specific types of health centers, such as consolidated
health centers or federally qualified health center look-alikes, are
not available. Data from reports provided by CMS officials show that in
2004, the most recent year for which complete data were available,
Medicare payments to federally qualified health centers totaled about
$278 million; in fiscal year 2004, the most recent year for which data
were available, Medicaid payments to federally qualified health centers
totaled about $778 million.
[C] Scholarship recipients must fulfill a service requirement by, for
example, being engaged in full-time private practice in a HPSA
addressing the health care needs of a substantial number of Indians.
Other types of service opportunities are also available for scholarship
recipients.
[D] A federal agency or state (including the District of Columbia,
Guam, Puerto Rico, and the U.S. Virgin Islands) can request J-1 visa
waivers for physicians who entered the United States for graduate
medical education under the Department of State's exchange visitor
program. After being recommended by the Department of State, waivers
are granted by USCIS. Three federal agencies--HHS, Appalachian Regional
Commission, and Delta Regional Authority--requested waivers for
physicians to practice in underserved areas in fiscal year 2005. Also
in fiscal year 2005, all 50 states, the District of Columbia, and Guam
requested J-1 visa waivers for physicians to practice in facilities
located in or treating residents of underserved areas under a provision
of the Immigration and Nationality Act, also known as the Conrad
Program.
[E] The Appalachian Regional Commission's and HHS's J-1 visa waiver
programs require waiver physicians to practice in HPSAs. The Delta
Regional Authority's J-1 visa waiver program requires waiver physicians
to practice in HPSAs, MUAs or MUPs.
[F] Individual state requirements may vary. For example, one state may
require J-1 visa waiver physicians to practice in HPSAs, while other
states may require them to practice in HPSAs, MUAs, or MUPs.
[G] National Health Service Corps programs include the Scholarship
Program, federal Loan Repayment Program, State Loan Repayment Program,
and Ready Responders.
[H] 8 U.S.C. § 1153(b)(2)(B)(ii), 8 C.F.R. § 204.12 (2006).
[I] According to CMS officials, the most recent completed year for
which data on rural health clinics were available was 2004 for Medicare
payments and fiscal year 2004 for Medicaid payments.
[J] Funding priorities are factors that provide a grant applicant with
a fixed amount of additional rating points, which could place the
applicant in a more favorable position to receive a grant award than
the applicant would be without the additional rating points.
[K] A medically underserved community is an urban or rural area or
population that (1) is eligible for HPSA designation; (2) is eligible
to be served by a community health center, migrant health center, or a
grantee serving residents of public housing or the homeless; (3) has a
shortage of personal health services, as determined under criteria
issued by the Secretary of Health and Human Services relating to rural
health clinics; or (4) is designated by a state governor (in
consultation with the medical community) as a shortage area or
medically underserved community.
[L] Includes 15 health professions education programs authorized under
title VII of the Public Health Service Act that have a funding
preference for applicants that place a high or increasing number of
graduates or those completing the program in settings having the
principal focus of serving medically underserved communities, including
(1) programs for training in family medicine, general internal
medicine, general pediatrics, physician assistants, general dentistry,
or pediatric dentistry; (2) programs for area health education centers;
(3) Health Education and Training Centers program; (4) Quentin N.
Burdick Program for Rural Interdisciplinary Training; (5) programs for
allied health projects and other disciplines; and (6) geriatric
education programs. In addition to these 15 programs, 1 additional
grant program authorized under title VII of the Public Health Service
Act, Health Administration Traineeships and Special Projects, has a
funding preference for applicants that have not less than 25 percent of
their graduates in full-time practice settings in medically underserved
communities, that recruit and admit students from medically underserved
communities, that have established relationships with public and
nonprofit providers of health care in the community involved, and that
emphasize employment with public and nonprofit entities in their
training of students.
[M] A funding preference is also available to applicants implementing
new programs if they meet at least four of seven statutory criteria.
[N] Includes the Advanced Education Nursing Traineeship Program and
Nurse Anesthetist Traineeship Program.
[O] The funding preference also applies to applicants that will help
meet public health nursing needs in state or local health departments.
Special considerations are factors considered in making funding
decisions that are not review criteria, preferences, or priorities, for
example, ensuring that there is an equitable geographic distribution of
grant recipients.
[End of table]
[End of section]
Appendix V: Comments from the Department of Health and Human Services:
Office of the Assistant Secretary for Legislation:
Department Of Health & Human Services:
Washington, D.C. 20201:
SEP 19 2006:
Leslie G. Aronovitz:
Director, Health Care:
U.S. Government Accountability Office:
Washington, DC 20548:
Dear Ms. Aronovitz:
Enclosed are the Department's comments on the U.S. Government
Accountability Office's (GAO) draft report entitled, "Health
Professional Shortage Areas: Problems Remain with Shortage Area
Designation System" (GAO-06-548), before its publication. These
comments represent the tentative position of the Department of Health
and Human Services and are subject to reevaluation when the final
version of this report is received.
The Department provided several technical comments directly to your
staff.
The Department appreciates the opportunity to comment on this draft
report before its publication.
Sincerely,
Signed by:
Vincent J. Ventimiglia, Jr.
Assistant Secretary for Legislation:
Comments Of The Department Of Health And Human Services On The U.S.
Government Accountability Office's (GAO) Draft Report "Health
Professional Shortage Areas: Problems Remain With Shortage Area
Designation System" GAO-0b-548:
General Comments:
The Department concurs with the two major recommendations, and is
pleased to report progress on both items. The Department has developed
a new methodology to address many of the issues raised in this report.
There are, however, some areas it the report that should be modified to
more accurately reflect the impact of the automatic designation process
and has provided some additional data for consideration in these areas.
The Department agrees with the Government Accountability Office (GAQ
that a more timely publication of the Federal Register listing is
necessary to assure that only those areas that meet the regulations
remain fully designated. Together, the Federal Register and HRSA on-
line data bases, accessible by the general public, serve as
notification of designated Health Professional Shortage Areas (HPSAs)
to all interested parties. Additionally, the Department informs
interested parties of new, continued, revised, or proposed for
withdrawal designations by way of a formal letter which states the
effective date of the action However, the Department is proposing a
change in the process of withdrawing Health Professional Shortage Areas
(HPSAs).
The Department agrees with the GAO that the current methodologies for
identifying areas and populations need to be revised to reflect the
current health care environment. In addition to the primary care
proposal referenced in this report, the Department is near completion
of a revised methodology for designating dental shortage areas. The
Department has also made significant progress in developing a revised
methodology for mental and behavioral health. Finally, the Department
is also near completion of the design of a totally new designation
process for identifying areas and facilities experiencing a shortage of
nurses. In the next 2 to 3 years, the Department hopes to have all of
these new designation methodologies completed and implemented. The
Department's goal is to designate shortage areas to facilitate access
to primary health care services for the people without such services.
The Department is always appreciative of suggestions to improve our
designation process, as we strive for excellence in service.
Impact of Automatic HPSA Designation for Federally Qualified Health
Centers and Selected Rural Health Clinics:
It is the Department's opinion that the report as currently drafted
gives a somewhat misleading assessment of the impact of the automatic
designation process, Since an estimated 50 percent or more of the
health centers were already in HPSAs, they would not be expected to be
helped by this provision. A slight rewording of the document in places
noted in the attachment would provide a more accurate assessment of the
process.
In the 2005 placement cycle of the National Health Service Corps
(NHSC), there were, in fact, 216 placements made to health centers as a
result of their automatic HPSA status. Of these, 6 were scholars, 209
were loan repayers, and 1 was a Ready Responder. At this point in the
2006 placement cycle, 108 placements have been completed or are pending
at health centers with automatic HPSAs. In 2005, approximately 16
percent of new NHSC placements were made to sites with a HPSA score of
"0." These are sites that clearly benefited from the new provision in
the designation process. Also, most State Loan Repayment programs do
not have scoring limits, so it is likely that some of these clinicians
were placed in health centers that are now eligible based on their
automatic status; 85 percent of the State Loan Repayment clinicians
serve in health centers.
In addition, it should be acknowledged that the Health Resources and
Services Administration (HRSA) took several steps to inform the health
centers and interested parties about the automatic scoring process and
how they could improve their scores if they wished. The scoring was
performed per established regulations to determine the greatest
shortage; in the absence of data being submitted, national data sources
were used. Information was posted on the HPSA Web site in the first
year after t he scores were developed in 2003 to provide alternative
data sources and options. The same information was shared with other
interested parties, including the Primary Care Offices (PCOs), which
are located in the State Health Departments. A number of sites took
advantage of this information and submitted additional data that
justified an increased score. In several cases, the backup data were
shared with the PCOs to explain the source of the current scores and
where alternative data could be applied.
Moreover, it should be recognized that the total number of HPSA sites
which can qualify to receive NHSC Scholars in any particular year is
limited by statute to no more than twice the number of scholars
available. The HPSA scoring process is designed to allow comparison of
relative need among sites, so that sites of greatest need will he
included on each year's list. It is not surprising that HPSA sites in
areas meeting the objective HPSA criteria typically score higher than
other facilities automatically designated.
It is also important to recognize that having a higher score and
obtaining a place on the scholarship list is no guarantee of getting a
clinician through the NHSC or the Health and Human Services (HHS) J-1
Visa Waiver program. Every year there are health centers on the
recruitment list that do not succeed in recruiting a clinician from the
scholarship program. Increasing the number of sites with higher scores
will increase the competition among health centers for an already
scarce resource, so a singular focus on the scores perhaps provides a
false sense of security for sites which feel that is the only obstacle
to successful recruiting.
Finally, in terms of the HHS J-1 Visa Waiver program, it is important
to recognize that this program has decreased dramatically with the
increase in the Conrad 3) programs at the State level. Therefore, the
fact that there was initially a higher score inquired for eligibility
for the Federal program had a very limited effect on the recruitment of
J-1 Visa physicians, most of whom are now going through the State
programs. In f act, in 2005 only 4 J-1 Visa Waivers were approved
through the HHS program, while approximately 900 were placed through
the State Conrad programs, most of which did not have a score limit.
GAO Recommendation:
Publish a list of designated HPSAs in the Federal Register or otherwise
remove, through Federal Register notification, the HPSA designations
for those HPSAs that no longer meet the criteria or have not provided
updated data in support of the their designation.
HHS Response:
The Department also concurs with GAO's recommendation that HRSA should
resume publishing lists of HPSA designations, or at least lists of HPSA
withdrawals in the Federal Register, to ensure that designations which
have already been proposed for withdrawal (by letter from the Bureau of
Health Profession's Shortage Designation Branch) actually get
withdrawn.
GAO Recommendation:
Complete and publish its proposal to revise the HPSA designation system
and address the shortcomings that have been identified in the current
methodology for designating HPSAs.
HHS Response:
The Department concurs with this recommendation that HRSA's already-
developed proposal to revise the regulations governing primary care
HPSA and Medically Underserved Area/Population (MUA/P) designations, in
the works since u 1998 Notice of Proposed Rule Making was withdrawn,
should be implemented as soon as possible. This would address the
various shortcomings of the existing criteria and process that GAO has
identified in this and previous reports.
HHS Overall Comment:
It should be clearly stated that this report covers only the primary
care designation process, and does not include the dental or mental
health processes. References to the scores and factors throughout the
report would be slightly different if all three disciplines were
included.
[End of section]
Appendix VI: GAO Contact and Staff Acknowledgments:
GAO Contact:
Leslie G. Aronovitz, (312) 220-7600 or aronovitzl@gao.gov:
Acknowledgments:
In addition to the person named above, Kim Yamane, Assistant Director;
Ellen W. Chu; Jennifer DeYoung; and Julian Klazkin made key
contributions to this report.
[End of section]
Related GAO Products:
Foreign Physicians: Preliminary Findings on the Use of J-1 Visa Waivers
to Practice in Underserved Areas. GAO-06-773T. Washington, D.C.: May
18, 2006.
Health Professions Education Programs: Action Still Needed to Measure
Impact. GAO-06-55. Washington, D.C.: February 28, 2006.
Health Centers: Competition for Grants and Efforts to Measure
Performance Have Increased. GAO-05-645. Washington, D.C.: July 13,
2005.
Health Centers and Rural Clinics: State and Federal Implementation
Issues for Medicaid's New Payment System. GAO-05-452. Washington, D.C.:
June 17, 2005.
Health Workforce: Ensuring Adequate Supply and Distribution Remains
Challenging. GAO-01-1042T. Washington, D.C.: August 1, 2001.
Health Care Access: Programs for Underserved Populations Could Be
Improved. GAO/T-HEHS-00-81. Washington, D.C.: March 23, 2000.
Physician Shortage Areas: Medicare Incentive Payments Not an Effective
Approach to Improve Access. GAO/HEHS-99-36. Washington, D.C.: February
26, 1999.
Health Care Access: Opportunities to Target Programs and Improve
Accountability. GAO/T-HEHS-97-204. Washington, D.C.: September 11,
1997.
Rural Health Clinics: Rising Program Expenditures Not Focused on
Improving Care in Isolated Areas. GAO/T-HEHS-97-65. Washington, D.C.:
February 13, 1997.
National Health Service Corps: Opportunities to Stretch Scarce Dollars
and Improve Provider Placement. GAO/HEHS-96-28. Washington, D.C.:
November 24, 1995.
Health Care Shortage Areas: Designations Not a Useful Tool for
Directing Resources to the Underserved. GAO/HEHS-95-200.Washington,
D.C.: September 8, 1995.
[End of section]
(290486):
FOOTNOTES
[1] Throughout this report, we use the term HPSA to denote health
professional shortage areas for primary care, which HHS considers to
include medical specialties of general or family practice, general
internal medicine, pediatrics, and obstetrics and gynecology. In
addition to primary care HPSAs, HHS designates HPSAs for fields other
than primary care, including dental and mental health.
[2] HPSAs can be located in all states and the District of Columbia, as
well as in American Samoa, the Commonwealth of the Northern Mariana
Islands, the Federated States of Micronesia, Guam, Puerto Rico, the
Republic of the Marshall Islands, the Republic of Palau, and the U.S.
Virgin Islands.
[3] Federally qualified health centers, referred to as health centers
in this report, include (1) health centers that receive a grant or
funding from a grant under the consolidated health center program
authorized under section 330 of the Public Health Service Act; (2)
facilities, called look-alikes, that are determined by the Secretary of
Health and Human Services to meet the requirements for receiving such a
grant; and (3) outpatient health programs or facilities operated by a
tribe or tribal organization under the Indian Self-Determination Act or
by an urban Indian organization receiving funds under title V of the
Indian Health Care Improvement Act. Health centers are located in both
urban and rural areas and are required to treat everyone regardless of
ability to pay. According to data from HHS's Health Resources and
Services Administration (HRSA), the agency that administers the
consolidated health center program and certifies look-alikes, there
were over 1,600 health centers as of September 2005.
[4] Rural health clinics are located in rural areas and, unlike health
centers, are not required to provide services to all individuals,
regardless of their ability to pay. According to data from HHS's
Centers for Medicare & Medicaid Services (CMS), the agency that
certifies these clinics as rural health clinics for purposes of the
Medicare and Medicaid programs, there were over 3,600 rural health
clinics as of September 2005.
[5] In addition to the ratio of population to primary care physicians,
HPSA designation is based on other factors, such as health care
resources available in neighboring areas. For those geographic HPSAs
that have their HPSA designations on the basis of having unusually high
needs for primary care services, the HPSA designations are also based
on at least one of three other factors: the area's infant mortality
rate, the percentage of the population with incomes below the poverty
level, or the area's birth rate. See HRSA, Bureau of Health
Professions, "Health Professional Shortage Area Primary Medical Care
Designation Criteria," http://bhpr.hrsa.gov/shortage/hpsacritpcm.htm
(downloaded May 15, 2006). HRSA also automatically designates health
centers and certain rural health clinics as facility HPSAs; these
facilities are not required to meet a ratio of population to primary
care physicians for HPSA designation.
[6] Four factors, including factors used for HPSA designation,
determine a HPSA's score--ratio of population to primary care
physicians, percentage of the population with incomes below the poverty
level, infant mortality rate or low birth weight rate, and time or
distance to the nearest source of primary care. Each HPSA is scored on
a scale of 0 to 25, with higher scores indicating greater relative need
for primary care providers. See appendix I for additional information
on HPSA scoring.
[7] Since 1995 we have reported on shortcomings of the HPSA designation
system. See GAO, Health Care Shortage Areas: Designations Not a Useful
Tool for Directing Resources to the Underserved, GAO/HEHS-95-200
(Washington, D.C.: Sept. 8, 1995), as well as "Related GAO Products" at
the end of this report.
[8] 63 Fed. Reg. 46538-55 (Sept. 1, 1998). The proposal included
provisions to combine the HPSA designation system with HRSA's other
designations of underservice: the medically underserved area (MUA) and
medically underserved population (MUP) designations. See appendix II
for more information on the MUA and MUP designations.
[9] Pub. L. No. 107-251, § 302(a)(1)(A), (e); 116 Stat. 1621, 1643-
1645. Under this act, health centers and those rural health clinics
certifying that they serve all individuals, regardless of ability to
pay, automatically receive designation as facility HPSAs.
[10] See appendix III for additional information on our scope and
methodology.
[11] HPSA designations may be requested for geographic areas,
population groups, and facilities located in all states and the
District of Columbia, as well as in American Samoa, the Commonwealth of
the Northern Mariana Islands, the Federated States of Micronesia, Guam,
Puerto Rico, the Republic of the Marshall Islands, the Republic of
Palau, and the U.S. Virgin Islands. The HPSA request and review process
is the same for all locations.
[12] State primary care offices work toward addressing the needs of the
medically underserved in their states and receive funding through HRSA
grants and cooperative agreements. For more information, see HRSA,
Bureau of Primary Health Care, "Directory of Primary Care Offices
(PCO): December 2005," http://bphc.hrsa.gov/OSNP/PCODirectory.htm
(downloaded June 19, 2006).
[13] See 42 C.F.R. pt. 5, apps. A-G (2005).
[14] 42 U.S.C. §§ 254e(a)(1), 254g(a)(1), 1395x(aa)(2), (4).
[15] Health centers are reimbursed under CMS's Medicare and Medicaid
programs using special payment mechanisms that serve as an incentive
for becoming a health center. See also GAO, Health Centers and Rural
Clinics: State and Federal Implementation Issues for Medicaid's New
Payment System, GAO-05-452 (Washington, D.C.: June 17, 2005).
[16] Some health centers receive grant funding from another entity that
is the recipient of such a grant. To be considered a health center,
they must also be eligible to receive a grant directly.
[17] A consolidated health center must serve an area or population
designated by HHS as an MUA or MUP. See appendix II for information on
the MUA and MUP designations.
[18] Rural health clinics are reimbursed under CMS's Medicare and
Medicaid programs using special payment mechanisms that serve as an
incentive for becoming a rural health clinic. To be reimbursed under
Medicare and Medicaid, a rural health clinic must be located in a
geographic or population-group HPSA in a rural area, a rural area
designated by a state's governor (or chief executive officer) and
certified by HHS as an area with a shortage of personal health
services, or a rural area HRSA has designated as an MUA. See appendix
II for additional information on the MUA designation.
[19] See appendix I for additional information on the scoring of HPSAs.
[20] A Primary Care Service Area is a zip code with one or more primary
care providers or any contiguous zip codes whose Medicare populations
seek the largest share of their primary care from those providers. For
more information, see Center for Evaluative Clinical Sciences at
Dartmouth, "The Primary Care Service Area Project,"
http://www.dartmouth.edu/~cecs/pcsa/pcsa.html# (downloaded Jan. 31,
2006).
[21] In addition, health centers that provide services at more than one
delivery site receive a HPSA score for the entire entity, which is
calculated by averaging the individual HPSA scores assigned to each
site. If any individual site of a health center is in a geographic or
population-group HPSA or has been designated as a facility HPSA through
the standard request and review process, the site may use that HPSA's
score for purposes of applying for federal programs.
[22] 42 U.S.C. § 254e(d)(1); 42 C.F.R. § 5.4(b) (2005).
[23] 42 U.S.C. § 254e(d)(2).
[24] 42 C.F.R. § 5.4(d) (2005).
[25] 42 U.S.C. § 254e(a)(1).
[26] Geographic HPSAs were also located in American Samoa, the
Commonwealth of the Northern Mariana Islands, the Federated States of
Micronesia, Guam, Puerto Rico, the Republic of the Marshall Islands,
and the Republic of Palau. Population-group HPSAs were also located in
Puerto Rico and the U.S. Virgin Islands.
[27] Of the 1,625 health centers that were automatically designated as
facility HPSAs as of September 2005, we estimated 989 were grantees
under HHS's consolidated health center program. (Consolidated health
center program grantees may provide services at more than one delivery
site, and although data were not available on the number of these
delivery sites, a HRSA official estimated that consolidated health
center program grantees operated more than 3,700 service delivery sites
in 2005.) In addition, we estimated 99 health center look-alikes and
537 tribal health centers were automatically designated as facility
HPSAs as of September 2005.
[28] Health centers with facility HPSA designations were also located
in American Samoa, Guam, Puerto Rico, the Republic of the Marshall
Islands, the Republic of Palau, and the U.S. Virgin Islands.
[29] As of September 2005, rural health clinics with facility HPSA
designations were located in all states except the following: Alaska,
Arizona, Connecticut, Delaware, Hawaii, Massachusetts, Maryland, New
Jersey, and Rhode Island, as well as the District of Columbia. Federal
or state correctional institutions with facility HPSA designations were
located in all states except Alaska, Delaware, North Dakota, and New
Mexico, as well as the District of Columbia. A federal or state
correctional institution with a facility HPSA designation was also
located in Puerto Rico.
[30] A fifth NHSC program--the Community Scholarship Program--did not
award any new scholarships in fiscal year 2005, and therefore we
excluded this program from our analysis.
[31] 42 U.S.C. § 254l(f)(1)(B)(v). Scholarship recipients receive
payment of tuition and other educational expenses, such as fees and
books, as well as a stipend for up to 4 years of education. For each
year of support received, the recipient is required to serve 1 year in
an NHSC-approved practice site in a high-need HPSA, with a minimum
service commitment of 2 years.
[32] NHSC providers must practice in NHSC-approved practice sites that
agree to use a sliding fee schedule or other method to reduce fees to
ensure that no financial barriers to care exist.
[33] 70 Fed. Reg. 51356-7 (Aug. 30, 2005). The minimum HPSA score for
the practice sites eligible for NHSC scholarship recipients in a given
year depends on both the practice sites applying for scholarship
recipients in that discipline and the number of scholarship recipients
graduating in each discipline that year.
[34] In this report, the numbers of NHSC providers represent those
primary care providers practicing in HPSAs to fulfill their service
obligation at the end of fiscal year 2005; they do not include about
550 NHSC dental providers and about 920 NHSC mental health providers
practicing in HPSAs designated for dental or mental health. The numbers
also exclude 13 NHSC loan repayment recipients who were chiropractors
or pharmacists practicing in HPSAs to fulfill their NHSC service
obligation under a demonstration project authorized by the Public
Health Service Act. See 42 U.S.C. § 254t.
[35] 42 U.S.C. § 254l-1(f), (g). For the 2-year minimum service
commitment, NHSC will pay up to $50,000, based on the loan repayment
recipient's qualifying educational loans, with the potential to
participate in the program for additional years, one year at a time,
with NHSC paying up to $35,000 per year. See HRSA, Bureau of Health
Professions, National Health Service Corps, "Loan Repayment Program,"
http://nhsc.bhpr.hrsa.gov/join_us/lrp.asp (downloaded May 13, 2006).
[36] 42 U.S.C. § 254q-1. States must provide matching funds to be
eligible for a grant.
[37] 69 Fed. Reg.70459 (Dec. 6, 2004). Applicants for the Ready
Responders must file a U.S. Public Health Service Commissioned Corps
application and meet the requirements for such commissioning. Initial
assignments will last up to 3 years, after which providers choosing to
stay in the U.S. Public Health Service move on to new assignments.
[38] See appendix IV for a list of programs using the HPSA designation
and HRSA's other designations of underservice (MUA and MUP) to allocate
resources or provide benefits in fiscal year 2005.
[39] 42 U.S.C. § 1395l(m).
[40] See appendix II for additional information on the MUA designation.
[41] The Appalachian Regional Commission is a federal-state economic
development partnership between the federal government and 13 states.
The commission initiates economic and community development programs
and serves as an advocate for the people in the Appalachian Region,
including all of West Virginia and parts of 12 other states: Alabama,
Georgia, Kentucky, Maryland, Mississippi, New York, North Carolina,
Ohio, Pennsylvania, South Carolina, Tennessee, and Virginia.
[42] The Delta Regional Authority is a federal-state partnership
between the federal government and eight states. The authority was
created to remedy severe and chronic economic distress by stimulating
economic development and fostering partnerships that will have a
positive impact on the economy of the region. The authority covers 240
counties and parishes in Alabama, Arkansas, Illinois, Kentucky,
Louisiana, Mississippi, Missouri, and Tennessee.
[43] Foreign physicians may enter the United States for graduate
medical education as participants under an exchange visitor program
administered by the Department of State. These physicians enter the
United States with J-1 visas and are required to return to their home
country or country of last legal residence for at least 2 years when
they complete their graduate medical education. They may, however,
obtain a waiver of this requirement from the Department of Homeland
Security's U.S. Citizenship and Immigration Services (USCIS) at the
request of a state or federal agency, if the physician has agreed to
practice in or work at a facility that treats residents of a geographic
area or areas designated by the Secretary of Heath and Human Services
as having a shortage of health care professionals, such as a HPSA, for
3 years. 8 U.S.C. § 1184(l)(1)(D). In May 2006, we testified that, in
fiscal year 2005, states and federal agencies requested more than 1,000
waivers for physicians--including those practicing primary care
specialties and those practicing nonprimary care specialties--to work
in facilities that are located in, or treat residents of, HPSAs or
other underserved areas. More than 90 percent of these were states'
waiver requests; less than 10 percent were federal agencies' requests.
See GAO, Foreign Physicians: Preliminary Findings on the Use of J-1
Visa Waivers to Practice in Underserved Areas, GAO-06-773T (Washington,
D.C.: May 18, 2006).
[44] Effective April 3, 2006, HHS revised its J-1 visa waiver policy.
Rather than require foreign physicians to practice in HPSAs with a
score of 14 or higher, the revised policy requires foreign physicians
seeking a waiver to practice in HPSAs with a score of 7 or higher in
order for HHS to request a J-1 visa waiver through its program. See
HHS, "Applications for Waiver of the Two-year Foreign Residence
Requirement (Clinical Care) of the Exchange Visitor Program,"
http://www.globalhealth.gov/newguidelines1.shtml (downloaded Mar. 17,
2006).
[45] See 42 U.S.C. §§ 295d(c), 295j. Funding preferences are factors
that place a grant application ahead of others without a preference on
a list of applicants recommended for funding by a review committee.
[46] 42 U.S.C. § 295p(6)(A), (B).
[47] Council on Graduate Medical Education, Department of Health and
Human Services, Health Resources and Services Administration, Tenth
Report: Physician Distribution and Health Care Challenges in Rural and
Inner-City Areas (Rockville, Md.: February 1998).
[48] Kevin Grumbach et al., "Physician Supply and Access to Care in
Urban Communities," Health Affairs, vol. 16, no. 1 (1997). For this
report, researchers analyzed data from a 1993 survey of a sample of
California residents from 41 urban communities based on guidelines for
defining primary care service areas developed by state agencies.
Researchers examined the relationship between income of the respondents
and the number of physicians per 100,000 population in those areas,
using data from the 1994 American Medical Association Physician
Masterfile for physicians in medical specialties of general or family
practice, general internal medicine, pediatrics, and obstetrics and
gynecology.
[49] See, for example, Council on Graduate Medical Education,
Department of Health and Human Services, Health Resources and Services
Administration, Tenth Report: Physician Distribution and Health Care
Challenges in Rural and Inner-City Areas, and Donald H. Taylor Jr. and
Thomas C. Ricketts, "Examining Alternative Measures of Medical
Underservice for Rural Areas: Executive Summary" (Working Paper No. 39,
North Carolina Rural Health Research Program, Cecil G. Sheps Center for
Health Services Research, University of North Carolina at Chapel Hill,
August 1995).
[50] See GAO/HEHS-95-200.
[51] This estimate was derived by subtracting the total number of
primary care providers practicing in HPSAs from the total number
reported as needed by the HPSA system. See GAO/HEHS-95-200.
[52] Not all HPSAs rely on county-level data. For example, in September
2005, although 831 geographic HPSAs were entire counties, 815
geographic HPSAs were portions of counties, such as census tracts.
[53] See John Robst and Glenn G. Graham, "The Relationship between the
Supply of Primary Care Physicians and Measures of Heath," Eastern
Economic Journal, vol. 30, no. 3 (2004), and Richard A. Wright et al.,
"Finding the Medically Underserved: A Need to Revise the Federal
Definition," Journal of Health Care for the Poor and Underserved, vol.
7, no. 4 (1996).
[54] Robst and Graham, "The Relationship between the Supply of Primary
Care Physicians and Measures of Heath."
[55] See, for example, Council on Graduate Medical Education,
Department of Health and Human Services, Health Resources and Services
Administration, Tenth Report: Physician Distribution and Health Care
Challenges in Rural and Inner-City Areas, and Taylor and Ricketts,
"Examining Alternative Measures of Medical Underservice for Rural
Areas: Executive Summary."
[56] Taylor and Ricketts, "Examining Alternative Measures of Medical
Underservice for Rural Areas: Executive Summary."
[57] Office of Inspector General, Department of Health and Human
Services, Status of the Rural Health Clinic Program, OEI-05-03-00170
(Chicago: August 2005). The Inspector General's review was limited to
those HPSAs where rural health clinics were located. HRSA stated in its
response to this report that the actual submission of updates of HPSA
data by interested parties and groups, and the review and action for
existing HPSA designations by HRSA, took place after the fourth or
possibly fifth year after a HPSA designation was received. HRSA also
stated that its ability to review depended on the number of requests
HRSA received for individual HPSA updates and the complexity of those
requests.
[58] 67 Fed. Reg. 7740-88 (Feb. 20, 2002).
[59] According to HRSA officials, the impact of not publishing a list
of designated HPSAs in the Federal Register may have been lessened
because (1) HRSA has a publicly available Web-based application that
can be used to search a regularly updated, real-time database of HPSA
designations, including those proposed for withdrawal, and (2) NHSC,
for which the HPSA designations were originally developed and the major
reason for the designations, does not place providers in HPSAs that are
proposed for withdrawal, so the absence of the Federal Register
publication has not affected the practice locations for NHSC programs.
HHS officials also noted that, for other programs that use the HPSA
designation, the decision to use or not use HPSAs proposed for
withdrawal is generally made by the individual programs.
[60] Of the 2,746 geographic and population-group HPSAs designated as
of January 2006, about 12 percent were proposed for withdrawal because
they no longer met the criteria or had not provided HRSA with updated
data in support of their designations.
[61] One tribal health center had not received a HPSA score from HRSA
as of September 2005. Although health centers receiving automatic
designation could also use the score of a geographic or population-
group HPSA if the facility was located in one, HRSA officials we spoke
with did not have data on how many health centers that were eligible
for this provision chose to use it when applying for federal programs.
[62] In addition to the NHSC Loan Repayment Program, health centers
with automatic facility HPSA designations were eligible to apply for
other programs that did not require a HPSA score, such as J-1 visa
waiver programs administered by the Appalachian Regional Commission,
the Delta Regional Authority, and many state health departments.
[63] See John A. Gale and Andrew F. Coburn, The Characteristics and
Roles of Rural Health Clinics in the United States: A Chartbook,
(Portland, Me.: Maine Rural Health Research Center, Institute for
Health Policy, Edmund S. Muskie School of Public Service, University of
Southern Maine, 2003). In addition, our analysis of data prepared for
HRSA's Office of Rural Health Policy using 2003 and 2004 CMS data on
rural health clinics and 2005 HRSA data on HPSAs indicated that nearly
half of all rural health clinics--including those that did not receive
automatic designation--were located in geographic or population-group
HPSAs.
[64] As of September 2005, 7 of the 590 rural health clinics that
received automatic HPSA designation had not received a HPSA score from
HRSA. Although rural health clinics receiving automatic designation
could also use the score of a geographic or population-group HPSA if
the facility was located in one, HRSA officials we spoke with did not
have data on how many rural health clinics that were eligible for this
provision chose to use it when applying for federal programs.
[65] In addition to the NHSC Loan Repayment Program, rural health
clinics with automatic facility HPSA designations were eligible to
apply for other programs that did not require a HPSA score, such as J-
1 visa waiver programs administered by the Appalachian Regional
Commission, the Delta Regional Authority, and many state health
departments.
[66] Criteria for designation of MUAs and MUPs are based on the index
of medical underservice, published in the Federal Register on October
15, 1976, and on the provisions of Pub. L. No. 99-280, enacted in 1986.
Areas or populations are scored on a scale of 0 to 100, where 0
represents completely underserved and 100 represents best served or
least underserved. Each service area or population group within an area
found to have a score of 62 or less qualifies for designation as an MUA
or MUP. See HRSA, Bureau of Health Professions, "Guidelines for
Medically Underserved Area and Population Designation,"
http://bhpr.hrsa.gov/shortage/muaguide.htm (downloaded on June 23,
2006).
[67] 63 Fed. Reg. 46538-55 (Sept. 1, 1998).
[68] Funding preferences are factors that place a grant application
ahead of others without a preference on a list of applicants
recommended for funding by a review committee.
[69] 42 U.S.C. § 295p(6). In fiscal year 2005 guidance to grant
applicants, HRSA stated that medically underserved communities include
health centers (including those for migrant workers, the homeless, and
residents of public housing); rural health clinics; National Health
Service Corps (NHSC) sites; Indian Health Service (IHS) sites; HPSAs;
state or local health departments; and sites in a shortage area
designated by a state governor.
[70] 42 U.S.C. § 295j. An additional grant program authorized under
title VII of the Public Health Service Act provides a funding
preference for applicants that have not less than 25 percent of their
graduates in full-time practice settings in medically underserved
communities, that recruit and admit students from medically underserved
communities, that have established relationships with public and
nonprofit providers of health care in the community involved, and that
emphasize employment with public and nonprofit entities in their
training of students. 42 U.S.C. § 295d(c).
[71] 42 U.S.C. § 296d. The preference also applies to applicants that
will help meet public health nursing needs in state or local health
departments.
[72] The HRSA Geospatial Data Warehouse provides a single point of
access to HRSA programmatic information, related health resources, and
demographic data for reporting on HRSA activities. The data warehouse
provides access to information for reporting and mapping of HRSA data,
including HPSAs. For more information, see HRSA, "HRSA Geospatial Data
Warehouse," http://datawarehouse.hrsa.gov (downloaded Mar. 12, 2006).
We downloaded data on HPSA designations as of September 2005 from the
data warehouse on October 27, 2005. We limited our analysis of the HPSA
database downloaded from the data warehouse to those data elements that
we determined, following discussion with HRSA officials, were reliable
for our purposes.
[73] We downloaded data on HPSA designations as of January 2006 from
HRSA's Geospatial Data Warehouse on March 12, 2006.
[74] As of May 2006, the HRSA official responsible for designating
HPSAs said that the agency was in the process of removing the duplicate
entries of health centers for Alaska Natives so these facilities would
be counted only once as a facility HPSA in HRSA's databases. The HRSA
official also reported that HRSA would remove duplicate public or
nonprofit medical facilities when these HPSA designations were reviewed
for continued eligibility.
[75] We reviewed information from these same sources to obtain
information on federal programs that use other federal designations of
medical underservice.
[76] The factors used to calculate the HPSA score were also generally
represented in our keywords.
[77] We identified reports as potentially relevant if they addressed
the relationship between key elements of the HPSA designation criteria
and primary care physician shortages or supply, including primary care
disciplines, such as pediatrics. We determined the following types of
reports not to be potentially relevant: those specific to other
disciplines or professions, such as dental care, chiropractic care,
specialty care, or nursing care; those related to recruitment and
retention of physicians that focused on physician characteristics;
those related to workforce projections; those using data from countries
other than the United States or focusing on health care markets outside
of the United States; and those with a narrow focus, such as on vaccine
shortages.
[78] We excluded reports that used state-level data because these data
are not necessarily applicable to smaller geographic units such as
counties, and HPSAs are often based on county boundaries or parts of
counties.
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