Health Resources and Services Administration
Many Underserved Areas Lack a Health Center Site, and the Health Center Program Needs More Oversight Gao ID: GAO-08-723 August 8, 2008Health centers funded through grants under the Health Center Program--managed by the Health Resources and Services Administration (HRSA), an agency in the U.S. Department of Health and Human Services (HHS)--provide comprehensive primary care services for the medically underserved. HRSA provides funding for training and technical assistance (TA) cooperative agreement recipients to assist grant applicants. GAO was asked to examine (1) to what extent medically underserved areas (MUA) lacked health center sites in 2006 and 2007 and (2) HRSA's oversight of training and TA cooperative agreement recipients' assistance to grant applicants and its provision of written feedback provided to unsuccessful applicants. To do this, GAO obtained and analyzed HRSA data, grant applications, and the written feedback provided to unsuccessful grant applicants and interviewed HRSA officials.
Grant awards for new health center sites in 2007 reduced the overall percentage of MUAs lacking a health center site from 47 percent in 2006 to 43 percent in 2007. In addition, GAO found wide geographic variation in the percentage of MUAs that lacked a health center site in both years. Most of the 2007 nationwide decline in the number of MUAs that lacked a site occurred in the South census region, in large part, because half of all awards made in 2007 for new health center sites were granted to the South census region. GAO also found that HRSA lacks readily available data on the services provided at individual health center sites. HRSA oversees training and TA cooperative agreement recipients, but its oversight is limited in key respects and it does not always provide clear feedback to unsuccessful grant applicants. HRSA oversees recipients using a number of methods, including regular communications, review of cooperative agreement applications, and comprehensive on-site reviews. However, the agency's oversight is limited because it lacks standardized performance measures to assess the performance of the cooperative agreement recipients and it is unlikely to meet its policy goal of conducting comprehensive on-site reviews of these recipients every 3 to 5 years. The lack of standardized performance measures limits HRSA's ability to effectively evaluate cooperative agreement recipients' activities that support the Health Center Program's goals with comparable measures. In addition, without timely comprehensive on-site reviews, HRSA does not have up-to-date comprehensive information on the performance of these recipients in supporting the Health Center Program. HRSA officials stated that they are in the process of developing standardized performance measures. Moreover, more than a third of the written feedback HRSA sent to unsuccessful Health Center Program grant applicants in fiscal years 2005 and 2007 contained unclear statements. The lack of clarity in this written feedback may undermine its usefulness rather than enhance the ability of applicants to successfully compete for grants in the future.
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Director: Team: Phone:GAO-08-723, Health Resources and Services Administration: Many Underserved Areas Lack a Health Center Site, and the Health Center Program Needs More Oversight
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Report to the Ranking Member, Subcommittee on Oversight and
Investigations, Committee on Energy and Commerce, House of
Representatives:
United States Government Accountability Office:
GAO:
August 2008:
Health Resources and Services Administration:
Many Underserved Areas Lack a Health Center Site, and the Health Center
Program Needs More Oversight:
GAO-08-723:
GAO Highlights:
Highlights of GAO-08-723, a report to the Ranking Member, Subcommittee
on Oversight and Investigations, Committee on Energy and Commerce,
House of Representatives.
Why GAO Did This Study:
Health centers funded through grants under the Health Center
Program”managed by the Health Resources and Services Administration
(HRSA), an agency in the U.S. Department of Health and Human Services
(HHS)”provide comprehensive primary care services for the medically
underserved. HRSA provides funding for training and technical
assistance (TA) cooperative agreement recipients to assist grant
applicants. GAO was asked to examine (1) to what extent medically
underserved areas (MUA) lacked health center sites in 2006 and 2007 and
(2) HRSA‘s oversight of training and TA cooperative agreement
recipients‘ assistance to grant applicants and its provision of written
feedback provided to unsuccessful applicants. To do this, GAO obtained
and analyzed HRSA data, grant applications, and the written feedback
provided to unsuccessful grant applicants and interviewed HRSA
officials.
What GAO Found:
Grant awards for new health center sites in 2007 reduced the overall
percentage of MUAs lacking a health center site from 47 percent in 2006
to 43 percent in 2007. In addition, GAO found wide geographic variation
in the percentage of MUAs that lacked a health center site in both
years. Most of the 2007 nationwide decline in the number of MUAs that
lacked a site occurred in the South census region, in large part,
because half of all awards made in 2007 for new health center sites
were granted to the South census region. GAO also found that HRSA lacks
readily available data on the services provided at individual health
center sites.
Figure: Percentages of MUAs That Lacked a Health Center Site, by Census
Region, 2006 and 2007:
[See PDF for image]
This figure is a map of the United States depicting the following data:
Census Region: Northeast;
MUAs lacking a health center site, 2006: 39%;
MUAs lacking a health center site, 2007: 37%.
Census Region: South;
MUAs lacking a health center site, 2006: 45%;
MUAs lacking a health center site, 2007: 40%.
Census Region: Midwest;
MUAs lacking a health center site, 2006: 62%;
MUAs lacking a health center site, 2007: 60%.
Census Region: West;
MUAs lacking a health center site, 2006: 32%;
MUAs lacking a health center site, 2007: 31%.
Source: Copyright, Corel Corp. All rights reserved (map); GAO analysis
of HRSA and U.S. Census Bureau data.
[End of figure]
HRSA oversees training and TA cooperative agreement recipients, but its
oversight is limited in key respects and it does not always provide
clear feedback to unsuccessful grant applicants. HRSA oversees
recipients using a number of methods, including regular communications,
review of cooperative agreement applications, and comprehensive on-site
reviews. However, the agency‘s oversight is limited because it lacks
standardized performance measures to assess the performance of the
cooperative agreement recipients and it is unlikely to meet its policy
goal of conducting comprehensive on-site reviews of these recipients
every 3 to 5 years. The lack of standardized performance measures
limits HRSA‘s ability to effectively evaluate cooperative agreement
recipients‘ activities that support the Health Center Program‘s goals
with comparable measures. In addition, without timely comprehensive on-
site reviews, HRSA does not have up-to-date comprehensive information
on the performance of these recipients in supporting the Health Center
Program. HRSA officials stated that they are in the process of
developing standardized performance measures. Moreover, more than a
third of the written feedback HRSA sent to unsuccessful Health Center
Program grant applicants in fiscal years 2005 and 2007 contained
unclear statements. The lack of clarity in this written feedback may
undermine its usefulness rather than enhance the ability of applicants
to successfully compete for grants in the future.
What GAO Recommends:
GAO is making recommendations to improve HRSA‘s oversight of
cooperative agreement recipients and the clarity of written feedback
provided to unsuccessful grant applicants. HHS concurred and plans to
implement these recommendations. However, HHS raised concerns with the
report scope and another recommendation to collect site-specific data.
GAO believes that the report scope is appropriate and that additional
data would benefit HRSA decision making.
To view the full product, including the scope and methodology, click on
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-723]. For more
information, contact Cynthia A. Bascetta at (202) 512-7114 or
bascettac@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
Almost Half of MUAs Lacked a Health Center Site in 2006, and the Types
of Services Provided by Each Site Could Not Be Determined:
2007 Awards Reduced the Number of MUAs That Lacked a Health Center
Site, but Wide Geographic Variation Remained:
HRSA Oversees Cooperative Agreement Recipients but Oversight Is Limited
in Key Respects, and Its Feedback to Unsuccessful Applicants Is Not
Always Clear:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Number and Percentage of Medically Underserved Areas (MUA)
Lacking a Health Center Site, 2006 and 2007:
Appendix II: Data on the 2007 High Poverty County New Access Point
Competition, by Census Region and State:
Appendix III: Comments from the U.S. Department of Health and Human
Services:
Appendix IV: GAO Contact and Staff Acknowledgments:
Tables:
Table 1: Description of Criteria and Maximum Points Awarded for New
Access Point Grant Opportunities, Fiscal Years 2005 and 2007:
Table 2: Number of MUAs That Lacked a Health Center Site for 2006 and
2007, and 2006 to 2007 Decrease in MUAs That Lacked a Health Center
Site by Number and Percentage, by Census Region:
Table 3: Number and Percentage of All New Access Point Grants Awarded
in 2007, by Census Region:
Table 4: Number and Percentage of New Access Point Grants Awarded in
Fiscal Year 2007 for the Open New Access Point Competition, by Census
Region:
Table 5: Total Number of Distinct Examples of Unclear Feedback by
Criterion for New Access Point Grant Applications from Fiscal Years
2005 and 2007:
Figures:
Figure 1: Percentage of MUAs That Lacked a Health Center Site, by
Census Region and State, 2006:
Figure 2: Percentage of MUAs That Lacked a Health Center Site, by
Census Region, 2007:
Figure 3: Geographic Distribution of Counties Targeted and Grants
Awarded for the 2007 High Poverty County New Access Point Competition:
Abbreviations:
HHS: U.S. Department of Health and Human Services:
HRSA: Health Resources and Services Administration:
MUA: medically underserved area:
MUP: medically underserved population:
PCA: primary care association:
TA: technical assistance:
UDS: uniform data system:
[End of section]
United States Government Accountability Office: Washington, DC 20548:
August 8, 2008:
The Honorable John M. Shimkus:
Ranking Member:
Subcommittee on Oversight and Investigations:
Committee on Energy and Commerce:
House of Representatives:
Dear Mr. Shimkus:
Health centers in the federal Health Center Program provide
comprehensive primary health care services--preventive, diagnostic,
treatment, and emergency services as well as referrals to specialty
care--to federally designated medically underserved populations (MUP)
or those individuals residing in federally designated medically
underserved areas (MUA).[Footnote 1] To fulfill the Health Center
Program's mission of increasing access to primary health care services
for the medically underserved, the Health Resources and Services
Administration (HRSA)--the agency within the U.S. Department of Health
and Human Services (HHS) that administers the Health Center Program--
provides grants to health centers. These grants, along with other
federal benefits available to health center grantees through the Health
Center Program, are an important part of successful health center
operations and viability.[Footnote 2] In 2006, Health Center Program
grants made up about 20 percent of all health center grantees'
revenues. A health center grantee may provide services at one or more
delivery sites--known as health center sites. Not all health center
sites are required to provide the full range of comprehensive primary
care services; some health center sites may provide only limited
services, such as dental and mental health services. In 2006,
approximately 1,000 health center grantees operated more than 6,000
health center sites while serving more than 15 million people.
Beginning in fiscal year 2002, HRSA significantly expanded the Health
Center Program under a 5-year effort--the President's Health Centers
Initiative--to increase access to comprehensive primary care services
for underserved populations, including those in MUAs. Under the
initiative, HRSA set a goal of awarding 630 grants to open new health
center sites--such grants are known as new access point grants--and 570
grants to expand services at existing health center sites by the end of
fiscal year 2006. New access point grants fund one or more new health
center sites operated by either new or existing health center grantees.
In July 2005, we reported challenges HRSA encountered during this
expansion of the Health Center Program.[Footnote 3] In particular, we
found that HRSA's process for awarding new access point grants might
not sufficiently target communities with the greatest need for
services, though we concluded that changes HRSA had made to its grant
award process could help the agency appropriately consider community
need when distributing federal resources. We also reported that HRSA
lacked reliable information on the number and location of the sites
where health centers provide care, and we recommended that HRSA collect
this information. In response to our recommendation, HRSA took steps to
improve its data collection efforts in 2006 to more reliably account
for the number and location of health center sites funded under the
Health Center Program.
By the end of fiscal year 2007, HRSA had achieved its grant goals under
the original President's Health Centers Initiative and launched a
second nationwide effort, the High Poverty County Presidential
Initiative. In fiscal year 2007, HRSA held two new access point
competitions, one focused on opening new health center sites in up to
200 HRSA-selected counties that lacked a health center site--part of
the High Poverty County Presidential Initiative--and one that was an
open competition.[Footnote 4]
To assist potential health center grantees in applying for new access
point grants, HRSA provides funds to national, regional, and state
organizations to promote Health Center Program grant opportunities and
help applicants secure funding. This funding mechanism is known as a
training and technical assistance (TA) cooperative agreement. For
fiscal year 2007, HRSA awarded nearly $53 million in cooperative
agreements to national organizations--specifically, those that assist
broadly with health center operations as well as expand access to
health care for underserved populations--and regional and state primary
care associations (PCA), organizations that also support health centers
and other safety net providers in increasing access to primary care
services. HRSA also assists potential grantees by providing written
feedback to applicants that apply for, but are not awarded, HRSA grants
through the Health Center Program. This written feedback--known as
summary statements--characterizes the strengths and weaknesses of the
applications. The summary statements are intended to help unsuccessful
applicants improve the quality--and therefore success--of future grant
applications. The summary statements are prepared by objective review
committees selected by HRSA to evaluate health center grant
applications. Before HRSA releases the statements to unsuccessful
applicants, the agency removes any internal recommendations made by the
committee and reviews them for accuracy.
Given the expansion of the Health Center Program under the President's
Health Centers Initiative and the High Poverty County Initiative as
well as HRSA's past challenges in targeting its new access point grant
awards to serve needy areas, you asked us to examine the extent to
which MUAs contain health center sites as well as HRSA's management of
the Health Center Program, specifically, efforts to assist applicants
for new access point grants. In this report, we examine (1) for 2006,
the extent to which MUAs lacked health center sites and the services
provided by each site in an MUA; (2) how new access point grants
awarded in 2007 changed the extent to which MUAs lacked health center
sites; and (3) HRSA's oversight of cooperative agreement recipients'
assistance to new access point applicants and feedback the agency
provides to unsuccessful applicants.
To examine the extent to which MUAs lacked health center sites
nationwide and the services provided by each site in 2006, we
interviewed HRSA officials and obtained health center site data from
HRSA's uniform data system (UDS). The UDS provided the zip code
location of health center sites as of December 31, 2006.[Footnote 5] We
also obtained from HRSA data on the geographic location of MUAs
designated for 2006. We linked the location of the MUAs to their
associated zip codes using a geographic crosswalk file based on U.S.
Census Bureau data.[Footnote 6] We then compared the location of health
center sites with the location of MUAs by census region and state.
[Footnote 7] We limited our analysis to health center sites operated by
grantees that received community health center funding--the type of
funding that requires sites to provide services to all residents of the
service area regardless of their ability to pay.[Footnote 8] In
addition, because HRSA takes into account the location of federally
qualified health center look-alike sites-- facilities that operate like
health center sites but do not receive HRSA funding[Footnote 9]--when
deciding where to award new access point grants, we obtained from HRSA
the location of health center look-alike sites in 2006 and compared
them with the location of MUAs.
To examine how new access point grants awarded in 2007 changed the
extent to which MUAs lacked health center sites nationwide, we obtained
from HRSA the applications submitted[Footnote 10] for the new access
point competitions held in fiscal year 2007 and the list of funded
applicants for these competitions.[Footnote 11] We reviewed the
applications to determine the zip code location of proposed new health
center sites, that is, sites for which the applicants requested
funding, and the list of funded applicants to determine the location of
the new health center sites for which grants were awarded in
2007.[Footnote 12] We also obtained from HRSA data on the location of
MUAs in 2007. We then compared the location of proposed and funded new
health center sites in 2007 with the location of MUAs in 2007.[Footnote
13] As with the 2006 analysis, we limited our review to health center
sites operated by grantees that requested community health center
funding--the type of funding that requires sites to provide services to
all residents of the service area regardless of their ability to pay.
As we did for the 2006 analysis, we obtained from HRSA the location of
health center look-alike sites in 2007 and compared them to the
location of MUAs in 2007.
To examine HRSA's oversight of cooperative agreement recipients'
assistance to new access point applicants, we first interviewed HRSA
officials and representatives from organizations that had training and
TA cooperative agreements with HRSA for fiscal year 2007 to provide
assistance to applicants for health center grants. Specifically, we
interviewed representatives of the eight national organizations that
target assistance to new access point applicants[Footnote 14] and a
judgmental sample of 10 geographically diverse state PCAs. We reviewed
copies of the organizations' notices of grant awards, work plans
(documents detailing health center training and technical assistance
activities), and semiannual and annual progress reports submitted to
HRSA.[Footnote 15] We examined documents obtained from HRSA relating to
its review of these cooperative agreement recipients' fiscal year 2007
annual noncompeting continuation applications[Footnote 16] and periodic
comprehensive on-site reviews conducted by HRSA. To evaluate HRSA's
feedback to unsuccessful applicants, we obtained from HRSA the summary
statements that were issued to unsuccessful applicants in connection
with each of the three new access point grant competitions held in
fiscal years 2005 and 2007.[Footnote 17] We selected a random sample of
30 percent of the summary statements based on application score. This
resulted in a sample of 69 summary statements out of the universe of
230 sent to unsuccessful applicants. The results of our analysis are
generalizable to this universe. For each summary statement, we reviewed
the information provided on the application's strengths and weaknesses
for each of the eight criteria used to evaluate new access point grant
applications.
We discussed our data sources with knowledgeable agency officials and
performed data reliability checks, such as examining the data for
missing values and obvious errors, to test the internal consistency and
reliability of the data. After taking these steps, we determined that
the data were sufficiently reliable for our purposes. We conducted our
work from April 2007 through July 2008 in accordance with generally
accepted government auditing standards. Those standards require that we
plan and perform the audit to obtain sufficient, appropriate evidence
to provide a reasonable basis for our findings and conclusions based on
our audit objectives. We believe that the evidence obtained provides a
reasonable basis for our findings and conclusions based on our audit
objectives.
Results in Brief:
In 2006, 47 percent of MUAs nationwide lacked a health center site;
however, the percentage of MUAs lacking a health center site varied
widely across census regions and states. For example, more than 60
percent of MUAs in the Midwest census region lacked a health center
site while approximately 30 percent of MUAs in the West census region
lacked a health center site. In addition, in some states, such as
Nebraska and Iowa, more than 80 percent of MUAs lacked a health center
site, while in other states, including Mississippi and California, less
than 25 percent of the MUAs lacked a health center site. We could not
determine the types of services provided by individual health center
sites in MUAs because HRSA does not collect and maintain data on the
types of services provided at each site. Because HRSA lacks readily
available data on the types of services provided at individual sites,
the extent to which individuals in MUAs have access to the full range
of comprehensive primary care services provided by health center sites
is unknown.
New access point awards made by HRSA in 2007 reduced the number of MUAs
that lacked a health center site nationwide by about 7 percent. As a
result, 43 percent of MUAs lacked a health center site in 2007. Wide
geographic variation in the percentage of MUAs lacking a health center
site remained. The West and Midwest census regions continued to show
the lowest and highest percentages of MUAs that lacked health center
sites, respectively. In addition, three of the census regions showed a
1 or 2 percentage point change since 2006, while the South census
region showed a 5 percentage point change. The minimal impact of the
2007 awards on geographic variation overall was due, in large part, to
the fact that the majority of the decline in MUAs that lacked a health
center site in 2007 was concentrated in the South census region, which
received the largest proportion of the awards made in 2007.
HRSA oversees training and TA cooperative agreement recipients that
assist new access point applicants using a number of methods, but its
oversight is limited in certain key respects, and its feedback to
unsuccessful applicants is not always clear. HRSA oversees recipients
using a number of methods, including regular communications, review of
cooperative agreement applications, and comprehensive on-site reviews.
However, the agency's oversight of cooperative agreement recipients has
limitations because the agency does not have standardized performance
measures to evaluate recipients' performance of training and technical
assistance activities. For example, HRSA does not require that
recipients be held to a performance measure that would report the
number of successful applicants each assisted. Without standardized
measures, HRSA cannot effectively assess recipients' performance and
compare the extent to which recipients' activities support the goals of
the Health Center Program. HRSA officials told us that they are
developing standardized measures to help the agency assess the
performance of its cooperative agreement recipients but provided no
details on specific measures they may implement. HRSA's oversight is
also limited because it is unlikely to meet its policy goal timeline of
conducting comprehensive on-site reviews of the recipients every 3 to 5
years. HRSA has conducted comprehensive on-site reviews for fewer than
one-quarter of its training and TA cooperative agreement recipients
that target assistance to new access point applicants since the agency
implemented these reviews in 2004. These reviews evaluate the overall
operations of cooperative agreement recipients and are intended to
improve the performance of HRSA programs. HRSA officials stated that
they had limited resources each year to review cooperative agreement
recipients. Moreover, to help unsuccessful applicants, HRSA sends
summary statements detailing the strengths and weaknesses of the
applications. However, 38 percent of the summary statements sent to
unsuccessful applicants for new access point grant competitions held in
fiscal years 2005 and 2007 contained unclear feedback. The lack of
clarity in the summary statements may undermine the usefulness of the
feedback for these applicants rather than enhance their ability to
successfully compete for new access point grants in the future.
To help improve the Health Center Program, we recommend that HRSA take
the following actions. First, to improve the agency's ability to
measure access to comprehensive primary care services in MUAs, we
recommend that HRSA collect and maintain readily available data on the
types of services provided at each health center site. Second, to
enhance the agency's oversight of training and TA cooperative agreement
recipients that assist grant applicants, we recommend that HRSA develop
and implement standardized performance measures for those recipients,
including a measure of the number of grant applicants an organization
assisted. Third, given HRSA's concerns about resources to conduct
comprehensive on-site reviews of cooperative agreement recipients each
year, we recommend that HRSA reevaluate its policy of reviewing
training and TA cooperative agreement funding recipients every 3 to 5
years and consider targeting its available resources to focus on
comprehensive on-site reviews for cooperative agreement recipients that
are most likely to benefit from such oversight. Finally, to improve the
clarity of the feedback the agency provides to unsuccessful grant
applicants, we recommend that HRSA identify and take appropriate action
to ensure that the discussion of applicants' strengths and weaknesses
in all summary statements is clear.
In commenting on a draft of this report, HHS raised concerns regarding
the scope of the report and one of our recommendations and concurred
with the other three recommendations. HHS stated that its most
significant concern was that we did not include MUPs in our analysis.
Our research objective was to determine the location of health center
sites that provide services to residents of an MUA and not to assess
how well areas or populations were served. Therefore, MUPs were beyond
the scope of our work. Moreover, in our MUA analysis, we covered the
health center sites of 90 percent of all Health Center Program
grantees. With regard to our recommendation that HRSA collect and
maintain data on the services provided at each health center site, HHS
acknowledged that site-specific information would be helpful for many
purposes, but said collecting this information would place a
significant burden on grantees and raise the program's administrative
expenses. We believe that having site-specific information on services
provided would help HRSA better measure access to comprehensive primary
health care services in MUAs when considering the placement of new
health center sites and facilitate the agency's ability to evaluate
service area overlap in MUAs.
Background:
The Health Center Program is governed by section 330 of the Public
Health Service Act.[Footnote 18] By law, grantees with community health
center funding must operate health center sites that:
* serve, in whole or in part, an MUA or MUP;
* provide comprehensive primary care services as well as enabling
services, such as translation and transportation, that facilitate
access to health care;
* are available to all residents of the health center service area,
with fees on a sliding scale based on patients' ability to pay;
* are governed by a community board of which at least 51 percent of the
members are patients of the health center; and:
* meet performance and accountability requirements regarding
administrative, clinical, and financial operations.
HRSA's MUA Designation Criteria:
HRSA may designate a geographic area--such as a group of contiguous
counties, a single county, or a portion of a county--as an MUA based on
the agency's index of medical underservice, composed of a weighted sum
of the area's infant mortality rate, percentage of population below the
federal poverty level, ratio of population to the number of primary
care physicians, and percentage of population aged 65 and over.
In previous reports, we identified problems with HRSA's methodology for
designating MUAs, including the agency's lack of timeliness in updating
its designation criteria.[Footnote 19] HRSA published a notice of
proposed rule making in 1998 to revise the MUA designation system, but
it was withdrawn because of a number of issues raised in over 800
public comments.[Footnote 20] In February 2008, HRSA published a
revised proposal and the period for pubic comment closed in June 2008.
[Footnote 21]
HRSA's New Access Point Grant Process:
HRSA uses a competitive process to award Health Center Program grants.
There are four types of health center grants available through the
Health Center Program, but only new access point grants are used to
establish new health center sites.[Footnote 22] Since 2005, HRSA has
evaluated applications for new access point grants using eight criteria
for which an application can receive a maximum of 100 points (see table
1).
Table 1: Description of Criteria and Maximum Points Awarded for New
Access Point Grant Opportunities, Fiscal Years 2005 and 2007:
Criterion: Need;
Description: The applicant's description of need in the proposed
service area;
Maximum points for the 2005 and 2007 open new access point competition:
10;
Maximum points for the 2007 high poverty county new access point
competition: 35.
Criterion: Response;
Description: The applicant's proposal to respond to the health care
need;
Maximum points for the 2005 and 2007 open new access point competition:
30;
Maximum points for the 2007 high poverty county new access point
competition: 20.
Criterion: Evaluative measures;
Description: The applicant's ability to measure its own performance;
Maximum points for the 2005 and 2007 open new access point competition:
10;
Maximum points for the 2007 high poverty county new access point
competition: 5.
Criterion: Impact;
Description: The applicant's justification of requested funding and how
it will increase access to care;
Maximum points for the 2005 and 2007 open new access point competition:
10;
Maximum points for the 2007 high poverty county new access point
competition: 6.
Criterion: Resources/capabilities;
Description: The applicant's organizational and financial plan and past
accomplishments;
Maximum points for the 2005 and 2007 open new access point competition:
15;
Maximum points for the 2007 high poverty county new access point
competition: 11.
Criterion: Support requested;
Description: The applicant's budget;
Maximum points for the 2005 and 2007 open new access point competition:
10;
Maximum points for the 2007 high poverty county new access point
competition: 8.
Criterion: Governance;
Description: The applicant's plans for establishing a governing board;
Maximum points for the 2005 and 2007 open new access point competition:
10;
Maximum points for the 2007 high poverty county new access point
competition: 10.
Criterion: Readiness;
Description: The applicant's ability to begin providing services;
Maximum points for the 2005 and 2007 open new access point competition:
5;
Maximum points for the 2007 high poverty county new access point
competition: 5.
Total:
Maximum points for the 2005 and 2007 open new access point competition:
100;
Maximum points for the 2007 high poverty county new access point
competition: 100.
Source: GAO analysis of HRSA's new access point health center
application guidance from fiscal years 2005 and 2007.
[End of table]
Grant applications are evaluated by an objective review committee--a
panel of independent experts, selected by HRSA, who have health center-
related experience. The objective review committee scores the
applications by awarding up to the maximum number of points allowed for
each criterion and prepares summary statements that detail an
application's strengths and weaknesses in each evaluative criterion.
The summary statements also contain the committee's recommended funding
amounts and advisory comments for HRSA's internal use; for example, the
committee may recommend that HRSA consider whether the applicant's
budgeted amount for physician salaries is appropriate. The committee
develops a rank order list--a list of all evaluated applications in
descending order by score. HRSA uses the internal comments--recommended
funding amounts and advisory comments--from the summary statements and
the rank order list when making final funding decisions. In addition,
HRSA is required to take into account the urban/rural distribution of
grants, the distribution of funds to different types of health centers,
and whether a health center site is located in a sparsely populated
rural area.[Footnote 23] HRSA also considers the geographic
distribution of health center sites--to determine if overlap exists in
the areas served by the sites--as well as the financial viability of
grantees.[Footnote 24] After the funding decisions are made, HRSA
officials review the summary statements for accuracy, remove the
recommended funding amounts and any advisory comments, and send the
summary statements to unsuccessful applicants as feedback.
HRSA's Training and TA Cooperative Agreements:
For fiscal year 2007, HRSA funded 60 training and TA cooperative
agreements with various national, regional, and state organizations to
support the Health Center Program, in part, by providing training and
technical assistance to health center grant applicants.[Footnote 25]
Cooperative agreements are a type of federal assistance that entails
substantial involvement between the government agency--in this case,
HRSA--and the funding recipient--that is, the national, regional, and
state organizations. HRSA relies on these training and TA cooperative
agreement recipients to identify underserved areas and populations
across the country in order to assist the agency in increasing access
to primary care services for underserved people. In addition, these
cooperative agreement recipients serve as HRSA's primary form of
outreach to potential applicants for health center grants.
For each cooperative agreement recipient, HRSA assigns a project
officer who serves as a recipient's main point of contact with the
agency. The duration of a cooperative agreement, known as the project
period, is generally 2 or 3 years, with each year known as a budget
period. As a condition of the cooperative agreements, HRSA project
officers and the organizations jointly develop work plans detailing the
specific training and technical assistance activities to be conducted
during each budget period. Activities targeted to new access point
applicants can include assistance with assessing community needs,
disseminating information in underserved communities regarding health
center program requirements, and developing and writing grant
applications. After cooperative agreement recipients secure funding
through a competitive process, they reapply for annual funding through
what is known as a noncompeting continuation application each budget
period until the end of their project period. These continuation
applications typically include a work plan and budget for the upcoming
budget period and progress report on the organization's current
activities.
HRSA policy states that cooperative agreement recipients will undergo a
comprehensive on-site review by agency officials once every 3 to 5
years. During these comprehensive on-site reviews, HRSA evaluates the
cooperative agreement recipients using selected performance measures--
developed in collaboration with the organizations--and requires
recipients to develop action plans to improve operations if necessary.
The purpose of these reviews is for the agency to evaluate the overall
operations of all its funding recipients and improve the performance of
its programs.
Almost Half of MUAs Lacked a Health Center Site in 2006, and the Types
of Services Provided by Each Site Could Not Be Determined:
Almost half of MUAs nationwide lacked a health center site in 2006. The
percentage of MUAs that lacked a health center site varied widely
across census regions and states. We could not determine the types of
primary care services provided by health center sites in MUAs because
HRSA does not maintain data on the types of services offered at each
site. Because of this, the extent to which individuals in MUAs have
access to the full range of comprehensive primary care services
provided by health center sites is unknown.
Almost Half of MUAs Nationwide Lacked Health Center Sites in 2006, and
the Percentage of MUAs Lacking Sites Varied Widely by Census Region and
State:
Based on our analysis of HRSA data, we found that 47 percent of MUAs
nationwide--1,600 of 3,421--lacked a health center site in 2006.
[Footnote 26] We found wide variation among census regions-- Northeast,
Midwest, South, and West--and across states in the percentage of MUAs
that lacked health center sites. (See fig. 1.) The Midwest census
region had the most MUAs that lacked a health center site (62 percent)
while the West census region had the fewest MUAs that lacked a health
center site (32 percent).
Figure 1: Percentage of MUAs That Lacked a Health Center Site, by
Census Region and State, 2006:
[See PDF for image]
This figure is a map of the United States depicting the following data
with number of MUAs in a state in parenthesis:
Northeast Region: Regional average: 39%;
* Percentage of MUAs that lacked a health center site: 0%:
State: Rhode Island: (7).
* Percentage of MUAs that lacked a health center site: 1-25%:
State: Connecticut: (17);
State: Massachusetts: (40);
State: New Hampshire: (5);
State: New Jersey: (28).
* Percentage of MUAs that lacked a health center site: 26-50%:
State: Maine: (30);
State: New York: (115);
State: Pennsylvania: (137);
* Percentage of MUAs that lacked a health center site: 51-75%:
State: Vermont: (16).
* Percentage of MUAs that lacked a health center site: 76-100%:
None.
South Region: Regional average: 45%;
* Percentage of MUAs that lacked a health center site: 0%:
State: Delaware: (4);
State: District of Columbia: (9).
* Percentage of MUAs that lacked a health center site: 1-25%:
State: Alabama: (96);
State: Mississippi: (91);
State: South Carolina: (68);
State: West Virginia: (57).
* Percentage of MUAs that lacked a health center site: 26-50%:
State: Arkansas: (82);
State: Florida: (35);
State: Maryland: (38);
State: Tennessee: (101);
State: Virginia: (92).
* Percentage of MUAs that lacked a health center site: 51-75%:
State: Georgia: (147);
State: Kentucky: (78);
State: Louisiana: (73);
State: North Carolina: (107);
State: Oklahoma: (65);
State: Texas: (282).
* Percentage of MUAs that lacked a health center site: 76-100%:
None.
Midwest Region: Regional average: 62%;
* Percentage of MUAs that lacked a health center site: 0%:
None.
* Percentage of MUAs that lacked a health center site: 1-25%:
None.
* Percentage of MUAs that lacked a health center site: 26-50%:
State: Illinois: (145);
State: Michigan: (89);
State: Ohio: (111).
* Percentage of MUAs that lacked a health center site: 51-75%:
State: Indiana: (61);
State: Kansas: (66);
State: Missouri: (118);
State: North Dakota: (55);
State: South Dakota: (65);
State: Wisconsin: (67);
* Percentage of MUAs that lacked a health center site: 76-100%:
State: Iowa: (73);
State: Minnesota: (96);
State: Nebraska: (82).
West Region: Regional average: 362%;
* Percentage of MUAs that lacked a health center site: 0%:
State: Alaska: (17);
State: Hawaii: (4).
* Percentage of MUAs that lacked a health center site: 1-25%:
State: California: (165);
State: Colorado: (42);
State: New Mexico: (36);
* Percentage of MUAs that lacked a health center site: 26-50%:
State: Arizona: (33);
State: Idaho: (35);
State: Nevada: (8);
State: Oregon: (42);
State: Utah: (17);
State: Washington: (31);
* Percentage of MUAs that lacked a health center site: 51-75%:
State: Wyoming: (11).
* Percentage of MUAs that lacked a health center site: 76-100%:
State: Montana: (44).
Source: Copyright, Corel Corp. All rights reserved (map); GAO analysis
of HRSA and U.S. Census Bureau data.
Note: U.S. territories are not included in this map.
[End of figure]
More than three-quarters of the MUAs in 4 states--Nebraska (91
percent), Iowa (82 percent), Minnesota (77 percent), and Montana (77
percent)--lacked a health center site; in contrast, fewer than one-
quarter of the MUAs in 13 states--including Colorado (21 percent),
California (20 percent), Mississippi (20 percent), and West Virginia
(19 percent)--lacked a health center site. (See app. I for more detail
on the percentage of MUAs in each state and the U.S. territories that
lacked a health center site in 2006.)
In 2006, among all MUAs, 32 percent contained more than one health
center site; among MUAs with at least one health center site, 60
percent contained multiple health center sites. Almost half of all MUAs
in the West census region contained more than one health center site
while less than one-quarter of MUAs in the Midwest contained multiple
health center sites. The states with three-quarters or more of their
MUAs containing more than one health center site were Alaska,
Connecticut, the District of Columbia, Hawaii, New Hampshire, and Rhode
Island. In contrast, Nebraska, Iowa, and North Dakota were the states
where less than 10 percent of MUAs contained multiple sites.
The Types of Services Provided at Individual Sites Could Not Be
Determined Because Data Were Not Readily Available:
We could not determine the types of primary care services provided at
each health center site because HRSA does not collect and maintain
readily available data on the types of services provided at individual
health center sites. While HRSA requests information from applicants in
their grant applications on the services each site provides, in order
for HRSA to access and analyze individual health center site
information on the services provided, HRSA would have to retrieve this
information from the grant applications manually. HRSA separately
collects data through the UDS from each grantee on the types of
services it provides across all of its health center sites, but it does
not collect data on services provided at each site. Although each
grantee with community health center funding is required to provide the
full range of comprehensive primary care services, it is not required
to provide all services at each health center site it operates. HRSA
officials told us that some sites provide limited services--such as
dental or mental health services. Because HRSA lacks readily available
data on the types of services provided at individual sites, it cannot
determine the extent to which individuals in MUAs have access to the
full range of comprehensive primary care services provided by health
center sites. This lack of basic information can limit HRSA's ability
to assess the full range of primary care services available in needy
areas when considering the placement of new access points and limit the
agency's ability to evaluate service area overlap in MUAs.
2007 Awards Reduced the Number of MUAs That Lacked a Health Center
Site, but Wide Geographic Variation Remained:
Our analysis of new access point grants awarded in 2007 found that
these awards reduced the number of MUAs that lacked a health center
site by about 7 percent. Specifically, 113 fewer MUAs in 2007--or 1,487
MUAs in all--lacked a health center site when compared with the 1,600
MUAs that lacked a health center site in 2006. As a result, 43 percent
of MUAs nationwide lacked a health center site in 2007.[Footnote 27]
Despite the overall reduction in the percentage of MUAs nationwide that
lacked health center sites in 2007, regional variation remained. The
West and Midwest census regions continued to show the lowest and
highest percentages of MUAs that lacked health center sites,
respectively. (See fig. 2.) Three of the census regions showed a 1 or 2
percentage point change since 2006, while the South census region
showed a 5 percentage point change.
Figure 2: Percentage of MUAs That Lacked a Health Center Site, by
Census Region, 2007:
[See PDF for image]
This figure is a map of the United States depicting the following data:
Census Region: Northeast;
MUAs lacking a health center site, 2006: 39%;
MUAs lacking a health center site, 2007: 37%.
Census Region: South;
MUAs lacking a health center site, 2006: 45%;
MUAs lacking a health center site, 2007: 40%.
Census Region: Midwest;
MUAs lacking a health center site, 2006: 62%;
MUAs lacking a health center site, 2007: 60%.
Census Region: West;
MUAs lacking a health center site, 2006: 32%;
MUAs lacking a health center site, 2007: 31%.
Source: Copyright, Corel Corp. All rights reserved (map); GAO analysis
of HRSA and U.S. Census Bureau data.
[End of figure]
The minimal impact of the 2007 awards on regional variation is due, in
large part, to the fact that more than two-thirds of the nationwide
decline in the number of MUAs that lacked a health center site--77 out
of the 113 MUAs--occurred in the South census region. (See table 2.) In
contrast, only 24 of the 113 MUAs were located in the Midwest census
region, even though the Midwest had nearly as many MUAs that lacked a
health center site in 2006 as the South census region. Overall, while
the South census region experienced a decline of 12 percent in the
number of MUAs that lacked a health center site, the other census
regions experienced declines of approximately 4 percent.
Table 2: Number of MUAs That Lacked a Health Center Site for 2006 and
2007, and 2006 to 2007 Decrease in MUAs That Lacked a Health Center
Site by Number and Percentage, by Census Region:
Census region: Northeast;
Number of MUAs that lacked a health center site: 2006: 153;
Number of MUAs that lacked a health center site: 2007: 147;
Decrease in MUAs that lacked a health center site, 2006 to 2007:
Number: 6;
Decrease in MUAs that lacked a health center site, 2006 to 2007:
Percentage: 4.
Census region: Midwest;
Number of MUAs that lacked a health center site: 2006: 641;
Number of MUAs that lacked a health center site: 2007: 617;
Decrease in MUAs that lacked a health center site, 2006 to 2007:
Number: 24;
Decrease in MUAs that lacked a health center site, 2006 to 2007:
Percentage: 4.
Census region: South;
Number of MUAs that lacked a health center site: 2006: 651;
Number of MUAs that lacked a health center site: 2007: 574;
Decrease in MUAs that lacked a health center site, 2006 to 2007:
Number: 77;
Decrease in MUAs that lacked a health center site, 2006 to 2007:
Percentage: 12.
Census region: West;
Number of MUAs that lacked a health center site: 2006: 155;
Number of MUAs that lacked a health center site: 2007: 149;
Decrease in MUAs that lacked a health center site, 2006 to 2007:
Number: 6;
Decrease in MUAs that lacked a health center site, 2006 to 2007:
Percentage: 4.
Census region: Nationally;
Number of MUAs that lacked a health center site: 2006: 1,600;
Number of MUAs that lacked a health center site: 2007: 1,487;
Decrease in MUAs that lacked a health center site, 2006 to 2007:
Number: 113;
Decrease in MUAs that lacked a health center site, 2006 to 2007:
Percentage: 7.
Source: GAO analysis of HRSA data.
[End of table]
The South census region experienced the greatest decline in the number
of MUAs lacking a health center site in 2007 compared to other census
regions, in large part, because it was awarded more new access point
grants that year than any other region. (See table 3.) Specifically,
half of all new access point awards made in 2007--from two separate new
access point competitions--went to applicants from the South census
region.
Table 3: Number and Percentage of All New Access Point Grants Awarded
in 2007, by Census Region:
Census region: Midwest;
Grants awarded: Number: 39;
Grants awarded: Percentage: 19.
Census region: Northeast;
Grants awarded: Number: 15;
Grants awarded: Percentage: 7.
Census region: South;
Grants awarded: Number: 101;
Grants awarded: Percentage: 50.
Census region: West;
Grants awarded: Number: 47;
Grants awarded: Percentage: 23.
Census region: Total;
Grants awarded: Number: 202;
Grants awarded: Percentage: 100[A].
Source: GAO analysis of HRSA data.
[A] Percentages do not add to 100 because of rounding.
[End of table]
When we examined the High Poverty County new access point competition,
in which 200 counties were targeted by HRSA for new health center
sites, we found that 69 percent of those awards were granted to
applicants from the South census region. (See fig. 3.) The greater
number of awards made to the South census region for this competition
may be explained by the fact that nearly two-thirds of the 200 counties
targeted were located in the South census region. (For detail on the
High Poverty County new access point competition by census region and
state, see app. II.)
Figure 3: Geographic Distribution of Counties Targeted and Grants
Awarded for the 2007 High Poverty County New Access Point Competition:
[See PDF for image]
This figure is a multiple vertical bar graph depicting the following
data:
Census region: Midwest;
Counties targeted: 56;
Grants awarded: 18.
Census region: Northeast;
Counties targeted: 11;
Grants awarded: 3.
Census region: South;
Counties targeted: 128;
Grants awarded: 52.
Census region: West;
Counties targeted: 5;
Grants awarded: 2.
Source: GAO analysis of HRSA data.
[End of figure]
When we examined the open new access point competition, which did not
target specific areas, we found that the South census region also
received a greater number of awards than any other region under that
competition. Specifically, the South census region was granted nearly
40 percent of awards; in contrast, the Midwest received only 17 percent
of awards. (See table 4.)
Table 4: Number and Percentage of New Access Point Grants Awarded in
Fiscal Year 2007 for the Open New Access Point Competition, by Census
Region:
Census region: Midwest;
Grants awarded: Number: 21;
Grants awarded: Percentage: 17.
Census region: Northeast;
Grants awarded: Number: 12;
Grants awarded: Percentage: 9.
Census region: South;
Grants awarded: Number: 49;
Grants awarded: Percentage: 39.
Census region: West;
Grants awarded: Number: 45;
Grants awarded: Percentage: 35.
Census region: Total;
Grants awarded: Number: 127;
Grants awarded: Percentage: 100.
Source: GAO analysis of HRSA data.
[End of table]
HRSA Oversees Cooperative Agreement Recipients but Oversight Is Limited
in Key Respects, and Its Feedback to Unsuccessful Applicants Is Not
Always Clear:
HRSA oversees cooperative agreement recipients, but the agency's
oversight is limited because it does not have standardized performance
measures to assess the performance of the cooperative agreement
recipients in assisting new access point applicants and the agency is
unlikely to meet its policy timeline for conducting comprehensive on-
site reviews. Although HRSA officials told us that they were developing
standardized performance measures, they provided no details on the
specific measures that may be implemented. Moreover, more than a third
of the summary statements sent to unsuccessful applicants for new
access point competitions held in fiscal years 2005 and 2007 contained
unclear feedback.
HRSA Oversees Cooperative Agreement Recipients but Lacks Standardized
Performance Measures and Likely Will Not Complete All Comprehensive On-
site Reviews in a Timely Manner:
HRSA oversees the activities of its cooperative agreement recipients
using a number of methods. HRSA officials told us that over the course
of a budget period, project officers use regular telephone and
electronic communications to discuss cooperative agreement recipients'
activities as specified in work plans, review the status of these
activities, and help set priorities.[Footnote 28] According to HRSA
officials, there is no standard protocol for these communications, and
their frequency, duration, and content vary over the course of a budget
period and by recipient. HRSA staff also reviews annual noncompeting
continuation applications to determine whether the cooperative
agreement recipients provided an update on their progress, described
their activities and challenges, and developed a suitable work plan and
budget for the upcoming budget period. The progress reports submitted
by cooperative agreement recipients in these annual applications serve
as HRSA's primary form of documentation on the status of cooperative
agreement recipients' activities.[Footnote 29]
HRSA's oversight of training and TA cooperative agreement recipients is
based on performance measures tailored to the individual organization
rather than performance measures that are standardized across all
recipients. Specifically, HRSA uses individualized performance measures
in cooperative agreement recipients' work plans and comprehensive on-
site reviews to assess recipients' performance. For cooperative
agreement recipients' work plans, recipients propose training and
technical assistance activities in response to HRSA's cooperative
agreement application guidance, in which the agency provides general
guidelines and goals for the provision of training and technical
assistance to health center grant applicants. The guidance requires
recipients to develop performance measures for each activity in their
work plans.[Footnote 30] When we analyzed the work plans of the 8
national organizations and 10 PCAs with training and TA cooperative
agreements, we found that these measures varied by cooperative
agreement recipient. For example, we found that for national
organizations, performance measures varied from (1) documenting that
the organization's marketing materials were sent to PCAs to (2)
recording the number of specific technical assistance requests the
organization received to (3) producing monthly reports for HRSA
detailing information about potential applicants. For state PCAs,
measures varied from (1) the PCA providing application review as
requested to (2) holding specific training opportunities--such as
community development or board development--to (3) identifying a
specific number of applicants the PCA would assist during the budget
period. Because these performance measures vary for cooperative
agreement recipients' activities, HRSA does not have comparable
measures to evaluate the performance of these activities across
recipients.
HRSA's oversight of cooperative agreement recipients is limited in some
key respects. One limitation is that the agency does not have
standardized measures for its assessment of recipients' performance of
training and technical assistance activities. Without standardized
performance measures, HRSA cannot effectively assess the performance of
its cooperative agreement recipients with respect to the training and
technical assistance they provide to support Health Center Program
goals. For example, HRSA does not require that all training and TA
cooperative agreement recipients be held to a performance measure that
would report the number of successful applicants each cooperative
agreement recipient helped develop in underserved communities,
including MUAs. Standardized performance measures could help HRSA
identify how to better focus its resources to help strengthen the
performance of cooperative agreement recipients.
HRSA officials told us that they are developing performance measures
for the agency's cooperative agreement recipients, which they plan to
implement beginning with the next competitive funding announcement,
scheduled for fiscal year 2009. However, HRSA officials did not provide
details on the particular measures that it will implement, so it is
unclear to what extent the proposed measures will allow HRSA to assess
the performance of cooperative agreement recipients in supporting
Health Center Program goals through such efforts as developing
successful new access point grant applicants.
HRSA's oversight is also limited because the agency's comprehensive on-
site reviews of cooperative agreement recipients do not occur as
frequently as HRSA policy states.[Footnote 31] According to HRSA's
stated policy, the agency will conduct these reviews for each
cooperative agreement recipient every 3 to 5 years. The reviews are
intended to assess--and thereby potentially improve--the performance of
the cooperative agreement recipients in supporting the overall goals of
the Health Center Program. This support can include helping potential
applicants apply for health center grants, identifying underserved
areas and populations across the country, and helping HRSA increase
access to primary care services for underserved populations.
As part of the comprehensive on-site reviews, HRSA officials consult
with the relevant project officer, examine the scope of the activities
cooperative agreement recipients have described in their work plans and
reported in their progress reports, and develop performance measures in
collaboration with the recipient. Similar to the performance measures
in cooperative agreement recipients' work plans, the performance
measures used during comprehensive on-site reviews are also
individually tailored and vary by recipient. For example, during these
reviews, some recipients are assessed using performance measures that
include the number of training and technical assistance hours the
recipients provided; other recipients are assessed using measures that
include the number of applicants that were funded after receiving
technical assistance from the recipient or the percentage of the
state's uninsured population that is served by health center sites in
the Health Center Program.
After an assessment, HRSA asks the recipient to develop an action plan.
In these action plans, the reviewing HRSA officials may recommend
additional activities to improve the performance of the specific
measures they had identified during the review. For example, if the
agency concludes that a cooperative agreement recipient needs to
increase the percentage of the state's uninsured population served by
health center sites in the Health Center Program, it may recommend that
the recipient pursue strategies to develop a statewide health
professional recruitment program and identify other funding sources to
improve its ability to increase access to primary care for underserved
people.
Although HRSA's stated policy is to conduct on-site comprehensive
reviews of cooperative agreement recipients every 3 to 5 years, HRSA is
unlikely to meet this goal for its training and TA cooperative
recipients that target assistance to new access point applicants. In
the 4 years since HRSA implemented its policy for these reviews in
2004, the agency has evaluated only about 20 percent of cooperative
agreement recipients that provide training and technical assistance to
grant applicants. HRSA officials told us that they have limited
resources each year with which to fund the reviews. However, without
these reviews, HRSA does not have a means of obtaining comprehensive
information on the performance of cooperative agreement recipients in
supporting the Health Center Program, including information on ways the
recipients could improve the assistance they provide to new access
point applicants.
HRSA Provided Unclear Written Feedback to More Than a Third of
Unsuccessful Applicants:
More than a third of summary statements sent to unsuccessful applicants
from new access point grant competitions held in fiscal years 2005 and
2007 contained unclear feedback. Based on our analysis of 69 summary
statements, we found that 38 percent contained unclear feedback
associated with at least one of the eight evaluative criteria, while 13
percent contained unclear feedback in more than one criterion. We
defined feedback as unclear when, in regard to a particular criterion,
a characteristic of the application was noted as both a strength and a
weakness without a detailed explanation supporting each conclusion. We
found that 26 summary statements contained unclear feedback. We found
41 distinct examples of unclear feedback in the summary statements.
(See table 5.) HRSA's stated purpose in providing summary statements to
unsuccessful applicants is to improve the quality of future grant
applications. However, if the feedback HRSA provides in these
statements is unclear, it may undermine the usefulness of the feedback
for applicants and their ability to successfully compete for new access
point grants.
Table 5: Total Number of Distinct Examples of Unclear Feedback by
Criterion for New Access Point Grant Applications from Fiscal Years
2005 and 2007:
Criterion: Need;
Total number of distinct examples of unclear feedback: 11.
Criterion: Response;
Total number of distinct examples of unclear feedback: 7.
Criterion: Impact;
Total number of distinct examples of unclear feedback: 5.
Criterion: Support requested;
Total number of distinct examples of unclear feedback: 5.
Criterion: Evaluative measures;
Total number of distinct examples of unclear feedback: 4.
Criterion: Governance;
Total number of distinct examples of unclear feedback: 4.
Criterion: Readiness;
Total number of distinct examples of unclear feedback: 3.
Criterion: Resources/capabilities;
Total number of distinct examples of unclear feedback: 2.
Criterion: Total;
Total number of distinct examples of unclear feedback: 41.
Source: GAO analysis of a sample of HRSA summary statements from new
access point competitions from fiscal years 2005 and 2007.
[End of table]
Based on our analysis, the largest number of examples of unclear
feedback was found in the need criterion, in which applications are
evaluated on the description of the service area, communities, target
population--including the number served, encounter information, and
barriers---and the health care environment. For example, one summary
statement indicated that the application clearly demonstrated and
provided a compelling case for the significant health access problems
for the underserved target population. However, the summary statement
also noted that the application was insufficiently detailed and brief
in its description of the target population.
Seven of the examples of unclear feedback were found in the response
criterion, in which applications are evaluated on the applicant's
proposal to respond the target population's need. One summary statement
indicated that the application detailed a comprehensive plan for health
care services to be provided directly by the applicant or through its
established linkages with other providers, including a description of
procedures for follow-up on referrals or services with external
providers. The summary statement also indicated that the application
did not provide a clear plan of health service delivery, including
accountability among and between all subcontractors.
Conclusions:
Awarding new access point grants is central to HRSA's ongoing efforts
to increase access to primary health care services in MUAs. From 2006
to 2007, HRSA's recent new access point awards achieved modest success
in reducing the percentage of MUAs nationwide that lacked a health
center site. However, in 2007, 43 percent of MUAs continue to lack a
health center site, and the new access point awards made in 2007 had
little impact on the wide variation among census regions and states in
the percentage of MUAs lacking a health center site. The relatively
small effect of the 2007 awards on geographic variation may be
explained, in part, because the South census region received a greater
number of awards than other regions, even though the South was not the
region with the highest percentage of MUAs lacking a health center site
in 2006.
HRSA awards new access point grants to open new health center sites,
thus increasing access to primary health care services for underserved
populations in needy areas, including MUAs. However, HRSA's ability to
target these awards and place new health center sites in locations
where they are most needed is limited because HRSA does not collect and
maintain readily available information on the services provided at
individual health center sites. Having readily available information on
the services provided at each site is important for HRSA's effective
consideration of need when distributing federal resources for new
health center sites because each health center site may not provide the
full range of comprehensive primary care services. This information can
also help HRSA assess any potential overlap of services provided by
health center sites in MUAs.
HRSA could improve the number and quality of grant applications it
receives--and thereby broaden its potential pool of applicants--by
better monitoring the performance of cooperative agreement recipients
that assist applicants and by ensuring that the feedback unsuccessful
applicants receive is clear. However, limitations in HRSA's oversight
of the training and TA cooperative agreement recipients hamper the
agency's ability to identify recipients most in need of assistance.
Because HRSA does not have standardized performance measures for these
recipients--either for their work plan activities or for the
comprehensive on-site reviews--the agency cannot assess recipients'
performance using comparable measures and determine the extent to which
they support the overall goals of the Health Center Program. One
standardized performance measure that could help HRSA evaluate the
success of cooperative agreement recipients that assist new access
point applicants is the number of successful grant applicants each
cooperative agreement recipient develops; this standardized performance
measure could assist HRSA in determining where to focus its resources
to strengthen the performance of cooperative agreement recipients.
HRSA's allocation of available resources has made it unlikely that it
will meet its goal of conducting comprehensive on-site reviews of each
cooperative agreement recipient every 3 to 5 years. Without these
reviews, HRSA does not have comprehensive information on the
effectiveness of training and TA cooperative agreement recipients in
supporting the Health Center Program, including ways in which they
could improve their efforts to help grant applicants. Given the
agency's concern regarding available resources for its comprehensive on-
site reviews, developing and implementing standardized performance
measures for training and TA cooperative agreement recipients could
assist HRSA in determining the cost-effectiveness of its current
comprehensive on-site review policy and where to focus its limited
resources.
HRSA could potentially improve its pool of future applicants by
increasing the extent to which it provides clear feedback to
unsuccessful applicants on the strengths and weaknesses of their
applications. HRSA intends for these summary statements to be used by
applicants to improve the quality of future grant applications.
However, the unclear feedback HRSA has provided to some unsuccessful
applicants in fiscal years 2005 and 2007 does not provide those
applicants with clear information that could help them improve their
future applications. This could limit HRSA's ability to award new
access point grants to locations where such grants are needed most.
Recommendations for Executive Action:
We recommend that the Administrator of HRSA take the following four
actions to improve the Health Center Program:
* Collect and maintain readily available data on the types of services
provided at each health center site to improve the agency's ability to
measure access to comprehensive primary care services in MUAs.
* Develop and implement standardized performance measures for training
and TA cooperative recipients that assist applicants to improve HRSA's
ability to evaluate the performance of its training and TA cooperative
agreements. These standardized performance measures should include a
measure of the number of successful applicants a recipient assisted.
* Reevaluate its policy of requiring comprehensive on-site reviews of
Health Center Program training and TA cooperative agreement recipients
every 3 to 5 years and consider targeting its available resources at
comprehensive on-site reviews for cooperative agreement recipients that
would benefit most from such oversight.
* Identify and take appropriate action to ensure that the discussion of
an applicant's strengths and weaknesses in all summary statements is
clear.
Agency Comments and Our Evaluation:
In commenting on a draft of this report, HHS raised concerns regarding
the scope of the report and one of our recommendations and concurred
with the other three recommendations. (HHS's comments are reprinted in
app. III.) HHS also provided technical comments, which we incorporated
as appropriate.
HHS said its most significant concern was with our focus on MUAs and
the exclusion of MUPs from the scope of our report. In our analysis, we
included the health center sites of 90 percent of all Health Center
Program grantees. We excluded from our review sites that were
associated with the remaining 10 percent of grantees that received HRSA
funding to serve specific MUPs only because they are not required to
serve all residents of the service area.[Footnote 32] Given our
research objective to determine the location of health center sites
that provide services to residents of an MUA, we excluded these
specific MUPs and informed HRSA of our focus on health center sites and
MUAs. We agree with HHS's comment that it could be beneficial to have
information on the number of grants awarded to programs serving both
MUAs and MUPs generally to fully assess the coverage of health center
sites.
HHS also commented that our methodology did not account for the
proximity of potential health center sites located outside the boundary
of an MUA. While we did not explicitly account for the proximity of
potential health center sites located outside an MUA, we did include
the entire area of all zip codes associated with an MUA. As a result,
the geographic boundary of an MUA in our analysis may be larger than
that defined by HRSA, so our methodology erred on the side of
overestimating the number of MUAs that contained a health center site.
With regard to our reporting on the percentage of MUAs that lacked a
health center site, HHS stated that this indicator may be of limited
utility, because not all programs serving MUAs and MUPs are comparable
to each other due to differences in size, geographic location, and
specific demographic characteristics. Specifically, HHS commented that
our analysis presumed that the presence of one health center site was
sufficient to serve an MUA. In our work, we did not examine whether
MUAs were sufficiently served because this was beyond the scope of our
work. Moreover, since HRSA does not maintain site-specific information
on services provided and each site does not provide the same services,
we could not assess whether an MUA was sufficiently served. HHS also
noted that a health center site may not be the appropriate solution for
some small population MUAs; however, we believe it is reasonable to
expect that residents of an MUA--regardless of its size, geographic
location, and specific demographic characteristics--have access to the
full range of primary care services.
With regard to our first recommendation that HRSA collect and maintain
site-specific data on the services provided at each health center site,
HHS acknowledged that site-specific information would be helpful for
many purposes, but it said collecting this information would place a
significant burden on grantees and raise the program's administrative
expenses. We believe that having site-specific information on services
provided would help HRSA better measure access to comprehensive primary
health care services in MUAs when considering the placement of new
health center sites and facilitate the agency's ability to evaluate
service area overlap in MUAs.
HHS concurred with our three other recommendations. With regard to our
second recommendation, HHS stated that HRSA will include standardized
performance measures with its fiscal year 2009 competitive application
cycle for state PCAs and that HRSA plans to develop such measures for
the national training and TA cooperative agreement recipients in future
funding opportunities. With regard to our third recommendation, HHS
commented that HRSA has developed a 5-year schedule for reviewing all
state PCA grantees. HHS also stated that HRSA is examining ways to
better target onsite reviews for national training and TA cooperative
agreement recipients that would most benefit from such a review.
Finally, HHS agreed with our fourth recommendation and stated that HRSA
is continuously identifying ways to improve the review of applications.
As arranged with your office, unless you publicly announce the contents
of this report earlier, we plan no further distribution of it until 30
days after its issue date. At that time, we will send copies of this
report to the Secretary of HHS, the Administrator of HRSA, appropriate
congressional committees, and other interested parties. We will also
make copies of this report available 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 have any questions about this report, please
contact me at (202) 512-7114 or bascettac@gao.gov. Contact points for
our Offices of Congressional Relations and Public Affairs may be found
on the last page of this report. Staff members who made major
contributions to this report are listed in appendix IV.
Sincerely yours,
Cynthia A. Bascetta:
Director, Health Care:
[End of section]
Appendix I: Number and Percentage of Medically Underserved Areas (MUA)
Lacking a Health Center Site, 2006 and 2007:
Midwest census region;
Total number of MUAs: 2006: 1,027;
Total number of MUAs: 2007: 1,029;
Number of MUAs lacking a health center site: 2006: 641;
Number of MUAs lacking a health center site: 2007: 617;
Percentage of MUAs lacking a health center site: 2006: 62;
Percentage of MUAs lacking a health center site: 2007: 60.
Midwest census region; Illinois;
Total number of MUAs: 2006: 146;
Total number of MUAs: 2007: 143;
Number of MUAs lacking a health center site: 2006: 71;
Number of MUAs lacking a health center site: 2007: 63;
Percentage of MUAs lacking a health center site: 2006: 49;
Percentage of MUAs lacking a health center site: 2007: 44.
Midwest census region; Indiana;
Total number of MUAs: 2006: 61;
Total number of MUAs: 2007: 61;
Number of MUAs lacking a health center site: 2006: 35;
Number of MUAs lacking a health center site: 2007: 34;
Percentage of MUAs lacking a health center site: 2006: 57;
Percentage of MUAs lacking a health center site: 2007: 56.
Midwest census region; Iowa;
Total number of MUAs: 2006: 73;
Total number of MUAs: 2007: 73;
Number of MUAs lacking a health center site: 2006: 60;
Number of MUAs lacking a health center site: 2007: 56;
Percentage of MUAs lacking a health center site: 2006: 82;
Percentage of MUAs lacking a health center site: 2007: 77.
Midwest census region; Kansas;
Total number of MUAs: 2006: 66;
Total number of MUAs: 2007: 71;
Number of MUAs lacking a health center site: 2006: 49;
Number of MUAs lacking a health center site: 2007: 52;
Percentage of MUAs lacking a health center site: 2006: 74;
Percentage of MUAs lacking a health center site: 2007: 73.
Midwest census region; Michigan;
Total number of MUAs: 2006: 89;
Total number of MUAs: 2007: 89;
Number of MUAs lacking a health center site: 2006: 44;
Number of MUAs lacking a health center site: 2007: 43;
Percentage of MUAs lacking a health center site: 2006: 49;
Percentage of MUAs lacking a health center site: 2007: 48.
Midwest census region; Minnesota;
Total number of MUAs: 2006: 96;
Total number of MUAs: 2007: 97;
Number of MUAs lacking a health center site: 2006: 74;
Number of MUAs lacking a health center site: 2007: 75;
Percentage of MUAs lacking a health center site: 2006: 77;
Percentage of MUAs lacking a health center site: 2007: 77.
Midwest census region; Missouri;
Total number of MUAs: 2006: 116;
Total number of MUAs: 2007: 116;
Number of MUAs lacking a health center site: 2006: 62;
Number of MUAs lacking a health center site: 2007: 58;
Percentage of MUAs lacking a health center site: 2006: 53;
Percentage of MUAs lacking a health center site: 2007: 50.
Midwest census region; Nebraska;
Total number of MUAs: 2006: 82;
Total number of MUAs: 2007: 82;
Number of MUAs lacking a health center site: 2006: 75;
Number of MUAs lacking a health center site: 2007: 73;
Percentage of MUAs lacking a health center site: 2006: 91;
Percentage of MUAs lacking a health center site: 2007: 89.
Midwest census region; North Dakota;
Total number of MUAs: 2006: 55;
Total number of MUAs: 2007: 55;
Number of MUAs lacking a health center site: 2006: 40;
Number of MUAs lacking a health center site: 2007: 39;
Percentage of MUAs lacking a health center site: 2006: 73;
Percentage of MUAs lacking a health center site: 2007: 71.
Midwest census region; Ohio;
Total number of MUAs: 2006: 111;
Total number of MUAs: 2007: 110;
Number of MUAs lacking a health center site: 2006: 48;
Number of MUAs lacking a health center site: 2007: 42;
Percentage of MUAs lacking a health center site: 2006: 43;
Percentage of MUAs lacking a health center site: 2007: 38.
Midwest census region; South Dakota;
Total number of MUAs: 2006: 65;
Total number of MUAs: 2007: 65;
Number of MUAs lacking a health center site: 2006: 40;
Number of MUAs lacking a health center site: 2007: 40;
Percentage of MUAs lacking a health center site: 2006: 62;
Percentage of MUAs lacking a health center site: 2007: 62.
Midwest census region; Wisconsin;
Total number of MUAs: 2006: 67;
Total number of MUAs: 2007: 67;
Number of MUAs lacking a health center site: 2006: 43;
Number of MUAs lacking a health center site: 2007: 42;
Percentage of MUAs lacking a health center site: 2006: 64;
Percentage of MUAs lacking a health center site: 2007: 63.
Northeast census region;
Total number of MUAs: 2006: 395;
Total number of MUAs: 2007: 400;
Number of MUAs lacking a health center site: 2006: 153;
Number of MUAs lacking a health center site: 2007: 147;
Percentage of MUAs lacking a health center site: 2006: 39;
Percentage of MUAs lacking a health center site: 2007: 37.
Northeast census region; Connecticut;
Total number of MUAs: 2006: 17;
Total number of MUAs: 2007: 17;
Number of MUAs lacking a health center site: 2006: 1;
Number of MUAs lacking a health center site: 2007: 1;
Percentage of MUAs lacking a health center site: 2006: 6;
Percentage of MUAs lacking a health center site: 2007: 6.
Northeast census region; Maine;
Total number of MUAs: 2006: 30;
Total number of MUAs: 2007: 32;
Number of MUAs lacking a health center site: 2006: 10;
Number of MUAs lacking a health center site: 2007: 11;
Percentage of MUAs lacking a health center site: 2006: 33;
Percentage of MUAs lacking a health center site: 2007: 34.
Northeast census region; Massachusetts;
Total number of MUAs: 2006: 40;
Total number of MUAs: 2007: 40;
Number of MUAs lacking a health center site: 2006: 10;
Number of MUAs lacking a health center site: 2007: 9;
Percentage of MUAs lacking a health center site: 2006: 25;
Percentage of MUAs lacking a health center site: 2007: 23.
Northeast census region; New Hampshire;
Total number of MUAs: 2006: 5;
Total number of MUAs: 2007: 5;
Number of MUAs lacking a health center site: 2006: 1;
Number of MUAs lacking a health center site: 2007: 1;
Percentage of MUAs lacking a health center site: 2006: 20;
Percentage of MUAs lacking a health center site: 2007: 20.
Northeast census region; New Jersey;
Total number of MUAs: 2006: 28;
Total number of MUAs: 2007: 28;
Number of MUAs lacking a health center site: 2006: 1;
Number of MUAs lacking a health center site: 2007: 1;
Percentage of MUAs lacking a health center site: 2006: 4;
Percentage of MUAs lacking a health center site: 2007: 4.
Northeast census region; New York;
Total number of MUAs: 2006: 115;
Total number of MUAs: 2007: 116;
Number of MUAs lacking a health center site: 2006: 56;
Number of MUAs lacking a health center site: 2007: 53;
Percentage of MUAs lacking a health center site: 2006: 49;
Percentage of MUAs lacking a health center site: 2007: 46.
Northeast census region; Pennsylvania;
Total number of MUAs: 2006: 137;
Total number of MUAs: 2007: 139;
Number of MUAs lacking a health center site: 2006: 63;
Number of MUAs lacking a health center site: 2007: 61;
Percentage of MUAs lacking a health center site: 2006: 46;
Percentage of MUAs lacking a health center site: 2007: 44.
Northeast census region; Rhode Island;
Total number of MUAs: 2006: 7;
Total number of MUAs: 2007: 7;
Number of MUAs lacking a health center site: 2006: 0;
Number of MUAs lacking a health center site: 2007: 0;
Percentage of MUAs lacking a health center site: 2006: 0;
Percentage of MUAs lacking a health center site: 2007: 0.
Northeast census region; Vermont;
Total number of MUAs: 2006: 16;
Total number of MUAs: 2007: 16;
Number of MUAs lacking a health center site: 2006: 11;
Number of MUAs lacking a health center site: 2007: 10;
Percentage of MUAs lacking a health center site: 2006: 69;
Percentage of MUAs lacking a health center site: 2007: 63.
South census region;
Total number of MUAs: 2006: 1,435;
Total number of MUAs: 2007: 1,441;
Number of MUAs lacking a health center site: 2006: 651;
Number of MUAs lacking a health center site: 2007: 574;
Percentage of MUAs lacking a health center site: 2006: 45;
Percentage of MUAs lacking a health center site: 2007: 40.
South census region; Alabama;
Total number of MUAs: 2006: 96;
Total number of MUAs: 2007: 96;
Number of MUAs lacking a health center site: 2006: 24;
Number of MUAs lacking a health center site: 2007: 19;
Percentage of MUAs lacking a health center site: 2006: 25;
Percentage of MUAs lacking a health center site: 2007: 20.
South census region; Arkansas;
Total number of MUAs: 2006: 92;
Total number of MUAs: 2007: 93;
Number of MUAs lacking a health center site: 2006: 38;
Number of MUAs lacking a health center site: 2007: 33;
Percentage of MUAs lacking a health center site: 2006: 41;
Percentage of MUAs lacking a health center site: 2007: 35.
South census region; Delaware;
Total number of MUAs: 2006: 4;
Total number of MUAs: 2007: 4;
Number of MUAs lacking a health center site: 2006: 0;
Number of MUAs lacking a health center site: 2007: 0;
Percentage of MUAs lacking a health center site: 2006: 0;
Percentage of MUAs lacking a health center site: 2007: 0.
South census region; District of Columbia; Total number of MUAs: 2006:
9; Total number of MUAs: 2007: 8;
Number of MUAs lacking a health center site: 2006: 1;
Number of MUAs lacking a health center site: 2007: 1;
Percentage of MUAs lacking a health center site: 2006: 11;
Percentage of MUAs lacking a health center site: 2007: 13.
South census region; Florida;
Total number of MUAs: 2006: 35;
Total number of MUAs: 2007: 35;
Number of MUAs lacking a health center site: 2006: 17;
Number of MUAs lacking a health center site: 2007: 15;
Percentage of MUAs lacking a health center site: 2006: 49;
Percentage of MUAs lacking a health center site: 2007: 43.
South census region; Georgia;
Total number of MUAs: 2006: 147;
Total number of MUAs: 2007: 149;
Number of MUAs lacking a health center site: 2006: 88;
Number of MUAs lacking a health center site: 2007: 78;
Percentage of MUAs lacking a health center site: 2006: 60;
Percentage of MUAs lacking a health center site: 2007: 52.
South census region; Kentucky;
Total number of MUAs: 2006: 78;
Total number of MUAs: 2007: 78;
Number of MUAs lacking a health center site: 2006: 51;
Number of MUAs lacking a health center site: 2007: 45;
Percentage of MUAs lacking a health center site: 2006: 65;
Percentage of MUAs lacking a health center site: 2007: 58.
South census region; Louisiana;
Total number of MUAs: 2006: 73;
Total number of MUAs: 2007: 73;
Number of MUAs lacking a health center site: 2006: 39;
Number of MUAs lacking a health center site: 2007: 33;
Percentage of MUAs lacking a health center site: 2006: 53;
Percentage of MUAs lacking a health center site: 2007: 45.
South census region; Maryland;
Total number of MUAs: 2006: 38;
Total number of MUAs: 2007: 38;
Number of MUAs lacking a health center site: 2006: 11;
Number of MUAs lacking a health center site: 2007: 10;
Percentage of MUAs lacking a health center site: 2006: 29;
Percentage of MUAs lacking a health center site: 2007: 26.
South census region; Mississippi;
Total number of MUAs: 2006: 91;
Total number of MUAs: 2007: 91;
Number of MUAs lacking a health center site: 2006: 18;
Number of MUAs lacking a health center site: 2007: 17;
Percentage of MUAs lacking a health center site: 2006: 20;
Percentage of MUAs lacking a health center site: 2007: 19.
South census region; North Carolina;
Total number of MUAs: 2006: 107;
Total number of MUAs: 2007: 108;
Number of MUAs lacking a health center site: 2006: 59;
Number of MUAs lacking a health center site: 2007: 55;
Percentage of MUAs lacking a health center site: 2006: 55;
Percentage of MUAs lacking a health center site: 2007: 51.
South census region; Oklahoma;
Total number of MUAs: 2006: 65;
Total number of MUAs: 2007: 66;
Number of MUAs lacking a health center site: 2006: 34;
Number of MUAs lacking a health center site: 2007: 30;
Percentage of MUAs lacking a health center site: 2006: 52;
Percentage of MUAs lacking a health center site: 2007: 45.
South census region; South Carolina;
Total number of MUAs: 2006: 68;
Total number of MUAs: 2007: 69;
Number of MUAs lacking a health center site: 2006: 17;
Number of MUAs lacking a health center site: 2007: 15;
Percentage of MUAs lacking a health center site: 2006: 25;
Percentage of MUAs lacking a health center site: 2007: 22.
South census region; Tennessee;
Total number of MUAs: 2006: 101;
Total number of MUAs: 2007: 101;
Number of MUAs lacking a health center site: 2006: 38;
Number of MUAs lacking a health center site: 2007: 35;
Percentage of MUAs lacking a health center site: 2006: 38;
Percentage of MUAs lacking a health center site: 2007: 35.
South census region; Texas;
Total number of MUAs: 2006: 282;
Total number of MUAs: 2007: 283;
Number of MUAs lacking a health center site: 2006: 167;
Number of MUAs lacking a health center site: 2007: 145;
Percentage of MUAs lacking a health center site: 2006: 59;
Percentage of MUAs lacking a health center site: 2007: 51.
South census region; Virginia;
Total number of MUAs: 2006: 92;
Total number of MUAs: 2007: 93;
Number of MUAs lacking a health center site: 2006: 38;
Number of MUAs lacking a health center site: 2007: 34;
Percentage of MUAs lacking a health center site: 2006: 41;
Percentage of MUAs lacking a health center site: 2007: 37.
South census region; West Virginia;
Total number of MUAs: 2006: 57;
Total number of MUAs: 2007: 56;
Number of MUAs lacking a health center site: 2006: 11;
Number of MUAs lacking a health center site: 2007: 9;
Percentage of MUAs lacking a health center site: 2006: 19;
Percentage of MUAs lacking a health center site: 2007: 16.
West census region;
Total number of MUAs: 2006: 485;
Total number of MUAs: 2007: 487;
Number of MUAs lacking a health center site: 2006: 155;
Number of MUAs lacking a health center site: 2007: 149;
Percentage of MUAs lacking a health center site: 2006: 32;
Percentage of MUAs lacking a health center site: 2007: 31.
West census region; Alaska;
Total number of MUAs: 2006: 17;
Total number of MUAs: 2007: 17;
Number of MUAs lacking a health center site: 2006: 0;
Number of MUAs lacking a health center site: 2007: 0;
Percentage of MUAs lacking a health center site: 2006: 0;
Percentage of MUAs lacking a health center site: 2007: 0.
West census region; Arizona;
Total number of MUAs: 2006: 33;
Total number of MUAs: 2007: 33;
Number of MUAs lacking a health center site: 2006: 13;
Number of MUAs lacking a health center site: 2007: 13;
Percentage of MUAs lacking a health center site: 2006: 39;
Percentage of MUAs lacking a health center site: 2007: 39.
West census region; California;
Total number of MUAs: 2006: 165;
Total number of MUAs: 2007: 167;
Number of MUAs lacking a health center site: 2006: 33;
Number of MUAs lacking a health center site: 2007: 31;
Percentage of MUAs lacking a health center site: 2006: 20;
Percentage of MUAs lacking a health center site: 2007: 19.
West census region; Colorado;
Total number of MUAs: 2006: 42;
Total number of MUAs: 2007: 42;
Number of MUAs lacking a health center site: 2006: 9;
Number of MUAs lacking a health center site: 2007: 9;
Percentage of MUAs lacking a health center site: 2006: 21;
Percentage of MUAs lacking a health center site: 2007: 21.
West census region; Hawaii;
Total number of MUAs: 2006: 4;
Total number of MUAs: 2007: 4;
Number of MUAs lacking a health center site: 2006: 0;
Number of MUAs lacking a health center site: 2007: 0;
Percentage of MUAs lacking a health center site: 2006: 0;
Percentage of MUAs lacking a health center site: 2007: 0.
West census region; Idaho;
Total number of MUAs: 2006: 35;
Total number of MUAs: 2007: 35;
Number of MUAs lacking a health center site: 2006: 15;
Number of MUAs lacking a health center site: 2007: 14;
Percentage of MUAs lacking a health center site: 2006: 43;
Percentage of MUAs lacking a health center site: 2007: 40.
West census region; Montana;
Total number of MUAs: 2006: 44;
Total number of MUAs: 2007: 44;
Number of MUAs lacking a health center site: 2006: 34;
Number of MUAs lacking a health center site: 2007: 33;
Percentage of MUAs lacking a health center site: 2006: 77;
Percentage of MUAs lacking a health center site: 2007: 75.
West census region; Nevada;
Total number of MUAs: 2006: 8;
Total number of MUAs: 2007: 8;
Number of MUAs lacking a health center site: 2006: 4;
Number of MUAs lacking a health center site: 2007: 4;
Percentage of MUAs lacking a health center site: 2006: 50;
Percentage of MUAs lacking a health center site: 2007: 50.
West census region; New Mexico;
Total number of MUAs: 2006: 36;
Total number of MUAs: 2007: 36;
Number of MUAs lacking a health center site: 2006: 5;
Number of MUAs lacking a health center site: 2007: 4;
Percentage of MUAs lacking a health center site: 2006: 14;
Percentage of MUAs lacking a health center site: 2007: 11.
West census region; Oregon;
Total number of MUAs: 2006: 42;
Total number of MUAs: 2007: 42;
Number of MUAs lacking a health center site: 2006: 17;
Number of MUAs lacking a health center site: 2007: 16;
Percentage of MUAs lacking a health center site: 2006: 40;
Percentage of MUAs lacking a health center site: 2007: 38.
West census region; Utah;
Total number of MUAs: 2006: 17;
Total number of MUAs: 2007: 17;
Number of MUAs lacking a health center site: 2006: 7;
Number of MUAs lacking a health center site: 2007: 7;
Percentage of MUAs lacking a health center site: 2006: 41;
Percentage of MUAs lacking a health center site: 2007: 41.
West census region; Washington;
Total number of MUAs: 2006: 31;
Total number of MUAs: 2007: 31;
Number of MUAs lacking a health center site: 2006: 12;
Number of MUAs lacking a health center site: 2007: 12;
Percentage of MUAs lacking a health center site: 2006: 39;
Percentage of MUAs lacking a health center site: 2007: 39.
West census region; Wyoming;
Total number of MUAs: 2006: 11;
Total number of MUAs: 2007: 11;
Number of MUAs lacking a health center site: 2006: 6;
Number of MUAs lacking a health center site: 2007: 6;
Percentage of MUAs lacking a health center site: 2006: 55;
Percentage of MUAs lacking a health center site: 2007: 55.
U.S. territories;
Total number of MUAs: 2006: 79;
Total number of MUAs: 2007: 79;
Number of MUAs lacking a health center site: 2006: 0;
Number of MUAs lacking a health center site: 2007: 0;
Percentage of MUAs lacking a health center site: 2006: 0;
Percentage of MUAs lacking a health center site: 2007: 0.
U.S. territories; American Samoa;
Total number of MUAs: 2006: 4;
Total number of MUAs: 2007: 4;
Number of MUAs lacking a health center site: 2006: 0;
Number of MUAs lacking a health center site: 2007: 0;
Percentage of MUAs lacking a health center site: 2006: 0;
Percentage of MUAs lacking a health center site: 2007: 0.
U.S. territories; Guam;
Total number of MUAs: 2006: 0;
Total number of MUAs: 2007: 0;
Number of MUAs lacking a health center site: 2006: n/a;
Number of MUAs lacking a health center site: 2007: n/a;
Percentage of MUAs lacking a health center site: 2006: n/a;
Percentage of MUAs lacking a health center site: 2007: n/a.
U.S. territories; Northern Mariana Islands;
Total number of MUAs: 2006: 0;
Total number of MUAs: 2007: 0;
Number of MUAs lacking a health center site: 2006: n/a;
Number of MUAs lacking a health center site: 2007: n/a;
Percentage of MUAs lacking a health center site: 2006: n/a;
Percentage of MUAs lacking a health center site: 2007: n/a.
U.S. territories; Puerto Rico;
Total number of MUAs: 2006: 72;
Total number of MUAs: 2007: 72;
Number of MUAs lacking a health center site: 2006: 0;
Number of MUAs lacking a health center site: 2007: 0;
Percentage of MUAs lacking a health center site: 2006: 0;
Percentage of MUAs lacking a health center site: 2007: 0.
U.S. territories; U.S. Virgin Islands;
Total number of MUAs: 2006: 3;
Total number of MUAs: 2007: 3;
Number of MUAs lacking a health center site: 2006: 0;
Number of MUAs lacking a health center site: 2007: 0;
Percentage of MUAs lacking a health center site: 2006: 0;
Percentage of MUAs lacking a health center site: 2007: 0.
Source: GAO analysis of Health Resources and Services Administration
(HRSA) and U.S. Census Bureau data.
[End of table]
[End of section]
Appendix II Data on the 2007 High Poverty County New Access Point
Competition, by Census Region and State:
Midwest census region;
Counties targeted by HRSA: Number: 56;
Counties targeted by HRSA: Percentage: 28;
Applications submitted: Number: 25;
Applications submitted: Percentage: 22;
Awards received: Number: 18;
Awards received: Percentage: 24.
Midwest census region; Illinois;
Counties targeted by HRSA: Number: 7;
Counties targeted by HRSA: Percentage: 4;
Applications submitted: Number: 3;
Applications submitted: Percentage: 3;
Awards received: Number: 3;
Awards received: Percentage: 4.
Midwest census region; Indiana;
Counties targeted by HRSA: Number: 10;
Counties targeted by HRSA: Percentage: 5;
Applications submitted: Number: 3;
Applications submitted: Percentage: 3;
Awards received: Number: 3;
Awards received: Percentage: 4.
Midwest census region; Iowa;
Counties targeted by HRSA: Number: 4;
Counties targeted by HRSA: Percentage: 2;
Applications submitted: Number: 3;
Applications submitted: Percentage: 3;
Awards received: Number: 3;
Awards received: Percentage: 4.
Midwest census region; Kansas;
Counties targeted by HRSA: Number: 2;
Counties targeted by HRSA: Percentage: 1;
Applications submitted: Number: 0;
Applications submitted: Percentage: 0;
Awards received: Number: n/a;
Awards received: Percentage: n/a.
Midwest census region; Michigan;
Counties targeted by HRSA: Number: 1;
Counties targeted by HRSA: Percentage: 1;
Applications submitted: Number: 3;
Applications submitted: Percentage: 3;
Awards received: Number: 1;
Awards received: Percentage: 1.
Midwest census region; Minnesota;
Counties targeted by HRSA: Number: 5;
Counties targeted by HRSA: Percentage: 3;
Applications submitted: Number: 0;
Applications submitted: Percentage: 0;
Awards received: Number: n/a;
Awards received: Percentage: n/a.
Midwest census region; Missouri;
Counties targeted by HRSA: Number: 11;
Counties targeted by HRSA: Percentage: 6;
Applications submitted: Number: 6;
Applications submitted: Percentage: 5;
Awards received: Number: 3;
Awards received: Percentage: 4.
Midwest census region; Nebraska;
Counties targeted by HRSA: Number: 3;
Counties targeted by HRSA: Percentage: 2;
Applications submitted: Number: 1;
Applications submitted: Percentage: 1;
Awards received: Number: 1;
Awards received: Percentage: 1.
Midwest census region; North Dakota;
Counties targeted by HRSA: Number: 2;
Counties targeted by HRSA: Percentage: 1;
Applications submitted: Number: 1;
Applications submitted: Percentage: 1;
Awards received: Number: 1;
Awards received: Percentage: 1.
Midwest census region; Ohio;
Counties targeted by HRSA: Number: 5;
Counties targeted by HRSA: Percentage: 3;
Applications submitted: Number: 4;
Applications submitted: Percentage: 4;
Awards received: Number: 2;
Awards received: Percentage: 3.
Midwest census region; South Dakota;
Counties targeted by HRSA: Number: 3;
Counties targeted by HRSA: Percentage: 2;
Applications submitted: Number: 0;
Applications submitted: Percentage: 0;
Awards received: Number: n/a;
Awards received: Percentage: n/a.
Midwest census region; Wisconsin;
Counties targeted by HRSA: Number: 3;
Counties targeted by HRSA: Percentage: 2;
Applications submitted: Number: 1;
Applications submitted: Percentage: 1;
Awards received: Number: 1;
Awards received: Percentage: 1.
Northeast census region;
Counties targeted by HRSA: Number: 11;
Counties targeted by HRSA: Percentage: 6;
Applications submitted: Number: 6;
Applications submitted: Percentage: 5;
Awards received: Number: 3;
Awards received: Percentage: 4.
Northeast census region; Connecticut;
Counties targeted by HRSA: Number: 0;
Counties targeted by HRSA: Percentage: 0;
Applications submitted: Number: 0;
Applications submitted: Percentage: 0;
Awards received: Number: n/a;
Awards received: Percentage: n/a.
Northeast census region; Maine;
Counties targeted by HRSA: Number: 0;
Counties targeted by HRSA: Percentage: 0;
Applications submitted: Number: 0;
Applications submitted: Percentage: 0;
Awards received: Number: n/a;
Awards received: Percentage: n/a.
Northeast census region; Massachusetts;
Counties targeted by HRSA: Number: 0;
Counties targeted by HRSA: Percentage: 0;
Applications submitted: Number: 0;
Applications submitted: Percentage: 0;
Awards received: Number: n/a;
Awards received: Percentage: n/a.
Northeast census region; New Hampshire;
Counties targeted by HRSA: Number: 0;
Counties targeted by HRSA: Percentage: 0;
Applications submitted: Number: 0;
Applications submitted: Percentage: 0;
Awards received: Number: n/a;
Awards received: Percentage: n/a.
Northeast census region; New Jersey;
Counties targeted by HRSA: Number: 0;
Counties targeted by HRSA: Percentage: 0;
Applications submitted: Number: 0;
Applications submitted: Percentage: 0;
Awards received: Number: n/a;
Awards received: Percentage: n/a.
Northeast census region; New York;
Counties targeted by HRSA: Number: 6;
Counties targeted by HRSA: Percentage: 3;
Applications submitted: Number: 4;
Applications submitted: Percentage: 4;
Awards received: Number: 2;
Awards received: Percentage: 3.
Northeast census region; Pennsylvania;
Counties targeted by HRSA: Number: 5;
Counties targeted by HRSA: Percentage: 3;
Applications submitted: Number: 2;
Applications submitted: Percentage: 2;
Awards received: Number: 1;
Awards received: Percentage: 1.
Northeast census region; Rhode Island;
Counties targeted by HRSA: Number: 0;
Counties targeted by HRSA: Percentage: 0;
Applications submitted: Number: 0;
Applications submitted: Percentage: 0;
Awards received: Number: n/a;
Awards received: Percentage: n/a.
Northeast census region; Vermont;
Counties targeted by HRSA: Number: 0;
Counties targeted by HRSA: Percentage: 0;
Applications submitted: Number: 0;
Applications submitted: Percentage: 0;
Awards received: Number: n/a;
Awards received: Percentage: n/a.
South census region;
Counties targeted by HRSA: Number: 128;
Counties targeted by HRSA: Percentage: 64;
Applications submitted: Number: 79;
Applications submitted: Percentage: 70;
Awards received: Number: 52;
Awards received: Percentage: 69.
South census region; Alabama;
Counties targeted by HRSA: Number: 4;
Counties targeted by HRSA: Percentage: 2;
Applications submitted: Number: 4;
Applications submitted: Percentage: 4;
Awards received: Number: 3;
Awards received: Percentage: 4.
South census region; Arkansas;
Counties targeted by HRSA: Number: 3;
Counties targeted by HRSA: Percentage: 2;
Applications submitted: Number: 3;
Applications submitted: Percentage: 3;
Awards received: Number: 2;
Awards received: Percentage: 3.
South census region; Delaware;
Counties targeted by HRSA: Number: 0;
Counties targeted by HRSA: Percentage: 0;
Applications submitted: Number: 0;
Applications submitted: Percentage: 0;
Awards received: Number: n/a;
Awards received: Percentage: n/a.
South census region; Florida;
Counties targeted by HRSA: Number: 6;
Counties targeted by HRSA: Percentage: 3;
Applications submitted: Number: 4;
Applications submitted: Percentage: 4;
Awards received: Number: 3;
Awards received: Percentage: 4.
South census region; Georgia;
Counties targeted by HRSA: Number: 19;
Counties targeted by HRSA: Percentage: 10;
Applications submitted: Number: 12;
Applications submitted: Percentage: 11;
Awards received: Number: 10;
Awards received: Percentage: 13.
South census region; Kentucky;
Counties targeted by HRSA: Number: 13;
Counties targeted by HRSA: Percentage: 7;
Applications submitted: Number: 7;
Applications submitted: Percentage: 6;
Awards received: Number: 2;
Awards received: Percentage: 3.
South census region; Louisiana;
Counties targeted by HRSA: Number: 13;
Counties targeted by HRSA: Percentage: 7;
Applications submitted: Number: 8;
Applications submitted: Percentage: 7;
Awards received: Number: 5;
Awards received: Percentage: 7.
South census region; Maryland;
Counties targeted by HRSA: Number: 0;
Counties targeted by HRSA: Percentage: 0;
Applications submitted: Number: 0;
Applications submitted: Percentage: 0;
Awards received: Number: n/a;
Awards received: Percentage: n/a.
South census region; Mississippi;
Counties targeted by HRSA: Number: 2;
Counties targeted by HRSA: Percentage: 1;
Applications submitted: Number: 3;
Applications submitted: Percentage: 3;
Awards received: Number: 1;
Awards received: Percentage: 1.
South census region; North Carolina;
Counties targeted by HRSA: Number: 16;
Counties targeted by HRSA: Percentage: 8;
Applications submitted: Number: 10;
Applications submitted: Percentage: 9;
Awards received: Number: 4;
Awards received: Percentage: 5.
South census region; Oklahoma;
Counties targeted by HRSA: Number: 3;
Counties targeted by HRSA: Percentage: 2;
Applications submitted: Number: 3;
Applications submitted: Percentage: 3;
Awards received: Number: 3;
Awards received: Percentage: 4.
South census region; South Carolina;
Counties targeted by HRSA: Number: 1;
Counties targeted by HRSA: Percentage: 1;
Applications submitted: Number: 0;
Applications submitted: Percentage: 0;
Awards received: Number: n/a;
Awards received: Percentage: n/a.
South census region; Tennessee;
Counties targeted by HRSA: Number: 3;
Counties targeted by HRSA: Percentage: 2;
Applications submitted: Number: 3;
Applications submitted: Percentage: 3;
Awards received: Number: 1;
Awards received: Percentage: 1.
South census region; Texas;
Counties targeted by HRSA: Number: 30;
Counties targeted by HRSA: Percentage: 15;
Applications submitted: Number: 14;
Applications submitted: Percentage: 12;
Awards received: Number: 10;
Awards received: Percentage: 13.
South census region; Virginia;
Counties targeted by HRSA: Number: 14;
Counties targeted by HRSA: Percentage: 7;
Applications submitted: Number: 6;
Applications submitted: Percentage: 5;
Awards received: Number: 6;
Awards received: Percentage: 8.
South census region; West Virginia;
Counties targeted by HRSA: Number: 1;
Counties targeted by HRSA: Percentage: 1;
Applications submitted: Number: 2;
Applications submitted: Percentage: 2;
Awards received: Number: 2;
Awards received: Percentage: 3.
West census region;
Counties targeted by HRSA: Number: 5;
Counties targeted by HRSA: Percentage: 3;
Applications submitted: Number: 3;
Applications submitted: Percentage: 3;
Awards received: Number: 2;
Awards received: Percentage: 3.
West census region; Alaska;
Counties targeted by HRSA: Number: 0;
Counties targeted by HRSA: Percentage: 0;
Applications submitted: Number: 0;
Applications submitted: Percentage: 0;
Awards received: Number: n/a;
Awards received: Percentage: n/a.
West census region; Arizona;
Counties targeted by HRSA: Number: 0;
Counties targeted by HRSA: Percentage: 0;
Applications submitted: Number: 0;
Applications submitted: Percentage: 0;
Awards received: Number: n/a;
Awards received: Percentage: n/a.
West census region; California;
Counties targeted by HRSA: Number: 0;
Counties targeted by HRSA: Percentage: 0;
Applications submitted: Number: 0;
Applications submitted: Percentage: 0;
Awards received: Number: n/a;
Awards received: Percentage: n/a.
West census region; Colorado;
Counties targeted by HRSA: Number: 1;
Counties targeted by HRSA: Percentage: 1;
Applications submitted: Number: 1;
Applications submitted: Percentage: 1;
Awards received: Number: 0;
Awards received: Percentage: 0.
West census region; Hawaii;
Counties targeted by HRSA: Number: 0;
Counties targeted by HRSA: Percentage: 0;
Applications submitted: Number: 0;
Applications submitted: Percentage: 0;
Awards received: Number: n/a;
Awards received: Percentage: n/a.
West census region; Idaho;
Counties targeted by HRSA: Number: 1;
Counties targeted by HRSA: Percentage: 1;
Applications submitted: Number: 1;
Applications submitted: Percentage: 1;
Awards received: Number: 1;
Awards received: Percentage: 1.
West census region; Montana;
Counties targeted by HRSA: Number: 1;
Counties targeted by HRSA: Percentage: 1;
Applications submitted: Number: 0;
Applications submitted: Percentage: 0;
Awards received: Number: n/a;
Awards received: Percentage: n/a.
West census region; Nevada;
Counties targeted by HRSA: Number: 1;
Counties targeted by HRSA: Percentage: 1;
Applications submitted: Number: 0;
Applications submitted: Percentage: 0;
Awards received: Number: n/a;
Awards received: Percentage: n/a.
West census region; New Mexico;
Counties targeted by HRSA: Number: 0;
Counties targeted by HRSA: Percentage: 0;
Applications submitted: Number: 0;
Applications submitted: Percentage: 0;
Awards received: Number: n/a;
Awards received: Percentage: n/a.
West census region; Oregon;
Counties targeted by HRSA: Number: 1;
Counties targeted by HRSA: Percentage: 1;
Applications submitted: Number: 1;
Applications submitted: Percentage: 1;
Awards received: Number: 1;
Awards received: Percentage: 1.
West census region; Utah;
Counties targeted by HRSA: Number: 0;
Counties targeted by HRSA: Percentage: 0;
Applications submitted: Number: 0;
Applications submitted: Percentage: 0;
Awards received: Number: n/a;
Awards received: Percentage: n/a.
West census region; Washington;
Counties targeted by HRSA: Number: 0;
Counties targeted by HRSA: Percentage: 0;
Applications submitted: Number: 0;
Applications submitted: Percentage: 0;
Awards received: Number: n/a;
Awards received: Percentage: n/a.
West census region; Wyoming;
Counties targeted by HRSA: Number: 0;
Counties targeted by HRSA: Percentage: 0;
Applications submitted: Number: 0;
Applications submitted: Percentage: 0;
Awards received: Number: n/a;
Awards received: Percentage: n/a.
Source: GAO analysis of HRSA and U.S. Census Bureau data.
[End of table]
[End of section]
Appendix III: Comments from the U.S. Department of Health and Human
Services:
Department Of Health & Human Services:
Office Of The Secretary:
Assistant Secretary for Legislation:
Washington, DC 20201:
July 10, 2008:
Cynthia A. Bascetta:
Director, Health Care:
441 G Street NW:
U.S. Government Accountability Office:
Washington, D.C. 20548:
Dear Ms. Bascetta:
Enclosed are the Department's comments on the U.S. Government
Accountability Office's (GAO) draft report entitled, "Health Resources
and Services Administration: Many Underserved Areas Lack a Health
Center Site, and the Consolidated Health Centers Program Needs More
Oversight" (GAO 08-723).
The Department appreciates the opportunity to comment on this draft
before its publication.
Sincerely,
Signed by:
Jennifer R. Luong, for:
Vincent J. Ventimiglia, Jr.
Assistant Secretary for Legislation:
Attachment:
General Comments for The Department of Health and Human Services'
Comments on Government Accountability Office's Draft Report: "Health
Resources And Services Administration: Many Underserved Areas Lack a
Health Service Site, and the Consolidated Health Centers Program Needs
More Oversight" (GAO-08-723):
The Department of Health and Human Services (HHS) appreciates the
opportunity to comment on the Government Accountability Office's (GAO)
draft report.
The most significant issue/concern with the report, which cannot be
corrected easily, is that the GAO did not investigate the extent to
which new projects were awarded to programs serving Medically
Underserved Populations (MUPs), as opposed to Medically Underserved
Areas (MUAs). This may be the result of the specific request from
Congress. MUPs may be within MUAs but also may be populations such as
uninsured and/or Medicaid recipients who are living within an area that
is not geographically an MUA, and it may be considerably easier for an
applicant to meet the MUP test. Knowing the breakdown between grants
awarded to MUAs versus MUPs would be useful information for planning
and for policy analysis purposes for HRSA. While it would be difficult
for the GAO to go back and gather that information now, it might be
beneficial to provide a footnote that explains why this study focuses
on geography, rather than population.
Please see below our comments on each of GAO's four recommendations.
GAO Recommendation #1:
GAO recommends that, in order to improve the agency's ability to ensure
access to comprehensive primary care services in MUAs, HRSA collect and
maintain readily available data on the types of services provided at
each health center site.
HHS Response:
The Health Center Program collects information on services by grantee,
not by individual site. While having available site specific
information would be useful for many purposes, collecting such
information at this level of detail would place a significant burden on
grantees and added administrative expenses on the program.
Site Data Collection:
Health centers arc required by statute to assure that all services
provided by the centers are available and accessible to patients served
by them. Even in cases where health centers have established service
delivery sites that provide more limited services, the health center
must still assure that all patients receiving care at any site have
access to the full range of services offered. For example, patients
seen at one site and found to have a need for services not available
there are referred to one of the other health center sites in the
center's service area for the specific service needed.
Also, regarding the second paragraph on page 16 of the report, HRSA
does not ask grantees for site level services information in an
application; therefore, data are not available to collect/analyze. HRSA
collects this information at the grantee level.
Percentage of MUAs that Lack a Health Center Site:
As stated in the draft report, Health Center Program grantees are
required to serve a federally designated MUA or MUP. This requirement
is implemented via HRSA's policy that a health center must serve, in
whole or in part, an MUA, but does not have to be physically located in
the MUA to serve it. The methodology to demonstrate MUAs served does
not take into account this HRSA policy. Therefore, HRSA suggests that
the study examine account for the proximity of a health center site to
the MUA in a standardized method in order to more accurately reflect
the HRSA policy for determining eligibility.
Further, the indicator "Percentage of MUAs that Lack a Health Center
Site" may be of limited utility, and analysis of this indicator by
State or Census Region may produce results that are misleading. This is
because all MUAs/MUPs are not necessarily comparable to each other.
Some MUAs arc whole counties; some arc groups of townships or other
census county subdivisions in rural areas; some are groups of census
tracts within metropolitan or micropolitan areas; and MUPs are
population groups, such as the low-income population of a particular
geographic area. Some MUA/Ps may have very small populations, others
very large; and a health center may not be the appropriate solution for
some small population MUAs.
Further, throughout the draft report, there is reference to the
agency's inability to evaluate service area overlap in MUAs, which does
not consider that service area overlap may be avoidable in serving a
MUA given its population and/or geographic size. Thus, it is not always
a fair comparison of MUAs and health center sites in MUAs, since there
is an assumption by GAO of a one-for-one ratio, i.e., that one site is
sufficient to serve one MUA.
GAO Recommendation #2:
GAO recommends that the agency, in order to enhance its oversight of
training and technical assistance (TA) cooperative agreement
recipients, develop and implement standardized performance measures for
those recipients, including a measure of the number of grant applicants
an organization assisted.
HHS Response:
HRSA concurs with this recommendation, and has developed standardized
performance measures that will be included as part of the competitive
FY 2009 application cycle for Primary Care Associations (PCAs). The
measures are designed to provide HRSA with the ability to measure
performance across the PCAs in providing training and TA to health
centers. As this application is still under review and clearance, HRSA
cannot share the measures at this time. HRSA also plans to develop
standardized performance measures for the national cooperative
agreements for inclusion in future funding opportunities.
GAO Recommendation #3:
GAO recommends that HRSA re-evaluate its policy of reviewing training
and TA cooperative agreement funding recipients every 3 to 5 years and
consider targeting its available resources to focus on comprehensive
onsite reviews for cooperative agreement recipients that are most
likely to benefit from such oversight.
HHS Response:
HRSA has developed a 5-year schedule for reviewing all State PCA
grantees through its State strategic partnership reviews. For national
cooperative agreements, HRSA is examining ways to better target on-site
reviews to those organizations that would most benefit from such a
review.
GAO Recommendation #4:
GAO recommends that, to improve the clarity of the feedback the agency
provides to unsuccessful grant applicants, HRSA identify and take
appropriate action to ensure that the discussion of applicants'
strengths and weaknesses in all summary statements is clear.
HHS Response:
HRSA agrees with this recommendation and is continuously identifying
ways to improve the review of applications, including summary review
statements.
[End of section]
Appendix IV: GAO Contact and Staff Acknowledgments:
GAO Contact:
Cynthia A. Bascetta, (202) 512-7114 or bascettac@gao.gov:
Acknowledgments:
In addition to the contact named above, Nancy Edwards, Assistant
Director; Stella Chiang; Krister Friday; Karen Howard; Daniel Ries;
Jessica Cobert Smith; Laurie F. Thurber; Jennifer Whitworth; Rachael
Wojnowicz; and Suzanne Worth made key contributions to this report.
[End of section]
Footnotes:
[1] The Health Resources and Services Administration designates MUAs
based on a geographic area, such as a county, while MUPs are based on a
specific population that demonstrates economic, cultural, or linguistic
barriers to primary care services. The people served by health centers
include Medicaid beneficiaries, the uninsured, and others who may have
difficulty obtaining access to health care.
[2] Other federal benefits include enhanced Medicaid and Medicare
payment rates and reduced drug pricing.
[3] GAO, Health Centers: Competition for Grants and Efforts to Measure
Performance Have Increased, [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-05-645] (Washington, D.C.: July 13, 2005).
[4] This new access point competition is described as open because
applicants were not required to be located in certain geographic areas
in order to apply but were required to demonstrate in the proposal that
the health center and its associated sites would serve, in whole or in
part, an MUA or MUP.
[5] Although grant competitions are scheduled according to the fiscal
year, the UDS reflects health center data as of December 31 of a
calendar year.
[6] Although only a portion of the geographic area of a zip code may be
included within the geographic boundary of an MUA, we included the
whole area of all zip codes associated with an MUA because we could not
identify geographic areas smaller than a zip code. As a result, in our
analysis, the geographic boundary of an MUA may be larger than that
defined by HRSA and a health center site may appear to be located in an
MUA when it is located outside the MUA. Therefore, we may overestimate
the number of MUAs that contain a health center site.
[7] In this report, we consider the District of Columbia a state.
[8] 42 U.S.C. § 254b(a)(1). In contrast, HRSA grantees that operate
health center sites targeting migrant farmworkers, public housing
residents, and the homeless are not required to serve all residents of
their service areas. 42 U.S.C. § 254b(a)(2). Because the UDS does not
allow separate identification of individual health center sites for
grantees that receive a combination of community health center funding
and health center funding to target migrant farmworkers, public housing
residents, or the homeless (27 percent of all grantees in 2006), we
could not distinguish sites supported exclusively by community health
center funding from sites supported exclusively by health center
funding for migrant farmworkers, public housing residents, or the
homeless. Therefore, we included all sites associated with health
center grantees that received, at a minimum, community health center
funding (90 percent of all grantees in 2006). As a result, some health
center sites included in our analysis are not sites exclusively
supported by community health center funding.
[9] Some organizations choose not to apply for funding under the Health
Center Program; however, they seek to be recognized by HRSA as
federally qualified health center look-alikes, in large part, so that
they may become eligible to receive other federal benefits, such as
enhanced Medicare and Medicaid payment rates and reduced drug pricing.
Federally qualified health center look-alike sites are referred to in
this report as health center look-alike sites.
[10] HRSA screens grant applications for eligibility, completeness, and
responsiveness to application and program requirements; those
applications not meeting these requirements are not considered for the
competition. Of 387 applications submitted for fiscal year 2007 new
access point competitions, 363 were found to be eligible for
consideration; our review was limited to these 363 applications.
[11] All new access point grants awarded in 2007 were made through two
new access point competitions held during fiscal year 2007, one of
which was an open competition and one of which limited applicants to
200 HRSA-selected counties as part of the High Poverty County
Presidential Initiative.
[12] We could not obtain those data from the UDS because it had not yet
been updated for 2007 at the time of our review.
[13] Because the UDS had not been updated for 2007 at the time of our
review, we could not determine whether any health center sites that
were in operation in 2006 were no longer operating in 2007; therefore,
we assumed that all health center sites operating in 2006 were still
operating in 2007.
[14] Although HRSA had training and TA cooperative agreements with 17
national organizations for fiscal year 2007, only 8 of these national
organizations targeted assistance to grant applicants.
[15] HRSA notifies cooperative agreement recipients of their funding
through a notice of grant award. Notices of grant awards are issued
according to a budget period.
[16] Noncompeting continuation applications that include work plans,
budgets, and progress reports are submitted annually by cooperative
agreement recipients for the duration of their cooperative agreements,
usually 2 to 3 years.
[17] HRSA awarded new access point grants in fiscal year 2006 based on
applications that had been submitted and reviewed under the fiscal year
2005 new access point competition. In order to examine unsuccessful new
access point applicants associated with fiscal year 2006, we reviewed
summary statements issued beginning in fiscal year 2005.
[18] Pub. L. No. 104-299, 110 Stat. 3626 (codified, as amended, at 42
U.S.C. § 254b).
[19] GAO, Health Professional Shortage Areas: Problems Remain with
Primary Care Shortage Area Designation System, [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-07-84] (Washington, D.C.: Oct.
24, 2006), and Health Care Shortage Areas: Designations Not a Useful
Tool for Directing Resources to the Underserved, [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-95-200] (Washington, D.C.:
Sept. 8, 1995).
[20] 63 Fed. Reg. 46,538 (Sept. 1, 1998).
[21] 73 Fed. Reg. 11,232 (Feb. 29, 2008).
[22] The other three types of Health Center Program grants are (1)
expanded medical capacity--to fund the expansion of an existing health
center or delivery site in order to significantly increase the
provision of comprehensive primary care services in areas of high need;
(2) service expansion--to provide opportunities for existing health
centers to expand and improve access to specialty health care services,
such as mental health and substance abuse, oral health, pharmacy, or
quality care management services; and (3) service area competition--to
open competition for an existing service area when a grantee's project
period, or the duration of its grant before it must compete to retain
its funding, is about to expire.
[23] 42 U.S.C. § 254b(k)(4), (r)(2)(B), (p).
[24] Center applications must demonstrate financial responsibility by
the use of accounting procedures as prescribed by HRSA. 42 U.S.C. §
254b(k)(3)(D).
[25] For fiscal year 2007, HRSA funded training and TA cooperative
agreements with 52 regional and state organizations and 8 national
organizations that target assistance to grant applicants.
[26] When we included the 294 health center look-alike sites operating
in 2006, we found that the percentage of MUAs lacking either a health
center site or health center look-alike site in 2006 was 46 percent (or
1,564 MUAs).
[27] When we included the 265 health center look-alike sites operating
in 2007, we found that 1,462 MUAs lacked a health center site or health
center look-alike site in 2007, which did not change the overall
percentage (43 percent) of MUAs in 2007 that lacked a health center
site.
[28] For the Health Center Program, HRSA has five project officers
assigned to 17 national training and TA cooperative agreement
recipients--of which eight organizations target assistance to grant
applicants--and nine project officers for the 52 regional and state
PCAs with training and TA cooperative agreements.
[29] In addition to annual reports, HRSA also uses semiannual reports
and midyear assessments to monitor the progress of cooperative
agreement recipients. Semiannual reports were discontinued in 2006 for
state PCAs, and semiannual progress reports were required for only four
of the eight national organizations that provided training and
technical assistance to health center applicants for the budget period
of 2006-2007. According to HRSA officials, semiannual reports for state
PCAs were phased out in 2006 because of their limited usefulness and
the reporting burden they posed to cooperative agreement recipients,
and they intend to oversee cooperative agreement recipients primarily
through reports provided on an annual basis. In addition, HRSA may
conduct midyear assessments if there are concerns with a cooperative
agreement recipient's performance. According to HRSA officials, only
two midyear assessments have been conducted for training and TA
cooperative agreement recipients since 2005 and no cooperative
agreements have been terminated for fiscal years 2006 and 2007 for
issues with performance.
[30] The work plan is further refined by both HRSA and the recipient in
accordance with the Health Center Program's priorities.
[31] According to HRSA policy, the agency conducts periodic
comprehensive on-site reviews of all funding recipients that support
the agency's programs.
[32] The specific populations served by these grantees are migrant
farmworkers, public housing residents, and homeless persons.
[End of section]
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(202) 512-4400:
U.S. Government Accountability Office:
441 G Street NW, Room 7125:
Washington, D.C. 20548:
Public Affairs:
Chuck Young, Managing Director, youngc1@gao.gov:
(202) 512-4800:
U.S. Government Accountability Office:
441 G Street NW, Room 7149:
Washington, D.C. 20548:
