a

GAO

United States Government Accountability Office

Report to the Honorable Judd Gregg, U.S. 

Senate

July 2005 HEALTH CENTERS

Competition for 

Grants and Efforts to 

Measure Performance 

Have Increased

GAO-05-645
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

www.gao.gov/cgi-bin/getrpt?GAO-05-645.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Marjorie Kanof, 

(202) 512-7119. 

Highlights of GAO-05-645, a report to the 

Honorable Judd Gregg, U.S. Senate 

July 2005

HEALTH CENTERS

Competition for Grants and Efforts to 

Measure Performance Have Increased 

Competition for Consolidated Health Centers program funding increased 

over the first 3 years of the President’s Health Centers Initiative, and HRSA’s 

process for assessing communities’ need for additional primary care sites is 

evolving. Program funding, which primarily supported continuing health 

center services, increased from fiscal year 2002 to fiscal year 2004. However, 

funding for new access point grants, which fund one or more new delivery 

sites, decreased by 53 percent during this period. At the same time, the 

number of applicants for these grants increased by 28 percent. As a result, 

the proportion of applicants receiving new access point grants declined from 

52 percent in fiscal year 2002 to 20 percent in fiscal year 2004. In fiscal years 

2002 through 2004, HRSA funded 334 new access point grants and 285 grants 

for expanded services at existing sites. While HRSA includes an assessment 

of communities’ need for services in its process for awarding new access 

point grants, agency officials indicated that they were not confident that the 

process has sufficiently targeted communities with the greatest need. 

Therefore, the agency is considering changes to the way it assesses 

community need and the relative weight it gives need in the award process. 

The number of health centers receiving new access point grants varied 

widely by state—from 1 to 57—during fiscal years 2002 through 2004, but 

HRSA lacks reliable data on the number and location of health centers’ 

delivery sites. Although HRSA uses data on the number of delivery sites to 

track the progress of the Consolidated Health Centers program, it is not 

confident that grantees are accurately identifying delivery sites funded by 

the program. Furthermore, in its reporting, HRSA counted each new access 

point grant funded in fiscal years 2002 through 2004 as a single delivery site, 

although some represent more than one site. HRSA needs to collect and 

report accurate and complete delivery site data to give the agency and the 

Congress data they need to make decisions about the program. 

HRSA has increased the role of performance measurement in its monitoring 

of health centers and has improved its collection of data that could help 

measure overall program performance. In 2004, the agency began to use a 

new process for on-site monitoring of health centers that focuses on each 

center’s performance on measures tailored to its community and patient 

population. However, the new review generally does not provide 

standardized performance information that HRSA can use to evaluate the 

health center program as a whole. The agency is using other tools to collect 

health outcome data on patients that could help measure program 

performance. Continued attention to such efforts could improve the agency’s 

ability to evaluate its success in improving the health of people in 

underserved communities. In addition to developing these data collection 

tools, HRSA has taken steps to improve the accuracy and completeness of its

Uniform Data System, a data set that HRSA uses to monitor aspects of the 

health centers’ performance. For example, HRSA provided grantees with 

more detailed instructions on how to identify their delivery sites. 

Health centers in the federal 

Consolidated Health Centers 

program provide comprehensive 

primary health care services at one 

or more delivery sites, without 

regard to patients’ ability to pay. In 

fiscal year 2002, the Health 

Resources and Services 

Administration (HRSA) began 

implementing the 5-year 

President’s Health Centers 

Initiative. The initiative’s goal is for 

the program to provide 1,200 grants 

in the neediest communities—630 

grants for new delivery sites and 

570 grants for expanded services at 

existing sites—by fiscal year 2006. 

GAO was asked to provide 

information on (1) funding of 

health centers and HRSA’s process 

for assessing the need for services, 

(2) geographic distribution of 

health centers, and (3) HRSA’s 

monitoring of health center 

performance. 

What GAO Recommends

GAO recommends that the 

Administrator of HRSA ensure that 

the agency collects reliable 

information from grantees on the 

number and location of delivery 

sites funded by the program and 

accurately reports this information 

to the Congress. HRSA said that it 

has efforts under way to increase 

the accuracy of delivery site data, 

but HRSA did not indicate whether 

it plans to revise its method of 

counting and reporting delivery 

sites to include all delivery sites 

funded since the President’s Health 

Centers Initiative began. 
Page i GAO-05-645 Health Centers

Contents

Letter 1

Results in Brief 3

Background 5

Competition for Health Center Funding Has Increased, and HRSA Is 

Evaluating Its Process for Assessing Need 12

Number of New Access Point Grantees Varies Widely by State, but 

HRSA Lacks Reliable Information on Delivery Sites 18

HRSA Has Increased the Role of Performance Measurement in 

Monitoring and Improved Its Collection of Health Center Data 21

Health Centers Often Face Challenges Securing Specialty Care for 

Patients 28

Conclusions 29

Recommendation for Executive Action 30

Agency Comments 30

Appendix I: Scope and Methodology 32

Appendix II: HRSA’s Process for Awarding Grants through the 

Consolidated Health Centers Program 35

Appendix III: Distribution of Consolidated Health Centers Program New 

Access Point Grants, Fiscal Years 2002 through 2004 41

Appendix IV: Distribution of Consolidated Health Centers Program 

Grantees, 2001 and 2003 43

Appendix V: Comments from the Health Resources and Services 

Administration 45

Appendix VI: GAO Contact and Staff Acknowledgments 47

Tables Table 1: Description of Competitive Grants Funded through the 

Consolidated Health Centers Program 9

Table 2: Review Criteria for New Access Point, Expanded Medical 

Capacity, Service Expansion, and Service Area 

Competition Grants, Fiscal Year 2004 38

Figures Figure 1: Health Centers’ Sources of Revenue, 2003 6

Figure 2: Allocation of Consolidated Health Centers Program 

Funding, by Type of Grant, Fiscal Years 2002 

through 2004 13

Figure 3: Disposition of Applications, by Type, Fiscal Years 2002 

through 2004 15
Contents

Page ii GAO-05-645 Health Centers

Figure 4: Health Center Grantees Funded through the 

Consolidated Health Centers Program, 2003 19

Abbreviations

BPHC Bureau of Primary Health Care

HHS Department of Health and Human Services

HRSA Health Resources and Services Administration

JCAHO Joint Commission on Accreditation of Healthcare Organizations

OPR Office of Performance Review

PCER Primary Care Effectiveness Review

UDS Uniform Data System

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Page 1 GAO-05-645 Health Centers

United States Government Accountability Office

Washington, D.C. 20548

A

July 13, 2005 Letr

The Honorable Judd Gregg

United States Senate

Dear Senator Gregg:

The nationwide network of health centers in the federal Consolidated 

Health Centers program is an important component of the health care 

safety net for vulnerable populations, including Medicaid beneficiaries,1

people who are uninsured, and others who may have difficulty obtaining 

access to health care. The centers provide comprehensive primary health 

care services—including preventive, diagnostic, treatment, and emergency 

services and referrals to specialty care2

—without regard to patients’ ability 

to pay. They also provide enabling services, such as transportation and 

translation, that help patients gain access to care. In 2003, through this 

program, the Department of Health and Human Services’ (HHS) Health 

Resources and Services Administration (HRSA) was funding nearly 900 

health centers with one or more delivery sites. The health centers provided 

comprehensive primary care services to over 12 million people—including 

over 4 million Medicaid patients and nearly 5 million uninsured patients. To 

increase access to health care for vulnerable populations, HRSA began 

implementing the 5-year President’s Health Centers Initiative in fiscal year 

2002. The initiative’s goals are for the Consolidated Health Centers program 

to provide 1,200 grants in the neediest communities—630 grants to health 

centers for new primary care delivery sites and 570 grants to health centers

1

Medicaid is a joint federal-state program that finances health insurance for certain lowincome adults and children.

2

Specialty care is health care services provided by medical professionals with advanced 

training focused on a specific field, such as cardiology, dermatology, and orthopedics.
Page 2 GAO-05-645 Health Centers

for expanded services at existing sites3— and increase the number of 

people served annually to about 16 million by the end of fiscal year 2006.4

Federal community and migrant health centers were established in the mid1960s, and other types of health centers—such as homeless and public 

housing centers—were established subsequently. The Health Centers 

Consolidation Act of 1996 created the Consolidated Health Centers 

program by combining these various types of health center programs under 

Section 330 of the Public Health Service Act.5

 In fiscal year 2004, funding 

for the Consolidated Health Centers program was about $1.6 billion, of 

which about $1.4 billion was allocated to grants for health centers. The 

Health Care Safety Net Amendments of 2002 reauthorized the Consolidated 

Health Centers program through fiscal year 2006.6

In light of the goals of the President’s Health Centers Initiative and in 

preparation for consideration of the reauthorization of the Consolidated 

Health Centers program, you asked us to provide information on the 

program, including health centers’ efforts to link patients with specialty 

care. In this report, we discuss (1) funding of health centers and HRSA’s 

process for assessing the need for services; (2) the geographic distribution 

of health centers; (3) HRSA’s monitoring of health center performance; and 

(4) health centers’ efforts to provide specialty care for their patients. 

To conduct our work, we analyzed national data that HRSA collects from 

health centers that receive grants through the Consolidated Health Centers 

program. We also reviewed information on health center funding, grant 

applications, and grant awards during fiscal years 2002 through 2004. We 

assessed the reliability of these data by interviewing agency officials 

3

New primary care delivery sites are sites that were not previously part of health centers 

funded by the Consolidated Health Centers program. These sites may be newly established 

facilities or facilities that already existed at the time their health center first received 

program funds. Sites providing expanded services are previously existing program sites 

whose health center is receiving additional funds to increase the site’s service capacity. 

4

HRSA reported that in fiscal year 2001, before the President’s Health Centers Initiative 

began, the number of primary care delivery sites whose health centers were receiving 

Consolidated Health Centers program funding was 3,317, and the number of people served 

was 10.3 million.

5

Pub. L. No. 104-299, 110 Stat. 3626 (1996) (codified at 42 U.S.C. § 254b). The Consolidated 

Health Centers program also funds school-based health centers.

6

Pub. L. No. 107-251, § 101, 116 Stat. 1621, 1622-27 (2002). 
Page 3 GAO-05-645 Health Centers

knowledgeable about the data and the systems that produced them, and we 

determined that the data were sufficiently reliable for the purposes of this 

report. We interviewed HRSA officials and representatives of state and 

national health center membership organizations and conducted structured 

interviews with officials of 12 health centers in urban and rural areas of 

California, Illinois, Pennsylvania, and Texas. We selected these states 

because they vary in geographic location and were among the states with 

the highest number of health centers. We conducted our work from August 

2004 through June 2005 in accordance with generally accepted government 

auditing standards. (For additional information on our methodology, see 

app. I.)

Results in Brief Competition for Consolidated Health Centers program funding increased 

over the first 3 years of the President’s Health Centers Initiative, and 

HRSA’s process for assessing communities’ need for additional health 

center delivery sites is evolving. Program funding, which primarily 

supported continuing health center services, increased from fiscal year 

2002 to fiscal year 2004. However, funding for new access point grants, 

which fund one or more new delivery sites operated by either new or 

existing grantees, decreased by 53 percent during this period. At the same 

time, the number of applicants for these grants increased by 28 percent. As 

a result, the proportion of applicants receiving new access point grants 

declined from 52 percent in fiscal year 2002 to 20 percent in fiscal year 

2004. While HRSA includes an assessment of communities’ need for 

services in its process for awarding new access point grants, agency 

officials indicated that they are not confident that the process has 

sufficiently targeted communities with the greatest need. Therefore, the 

agency is considering changes to the way it assesses community need and 

the relative weight it gives need in the award process. 

The number of health centers receiving new access point grants varied 

widely by state during fiscal years 2002 through 2004, but HRSA lacks 

reliable information on the number and location of the delivery sites where 

health centers provided care. During this period, about half of the 334 new 

access point grants HRSA awarded were in 10 states, and the number of 

grantees in each state ranged from 1 to 57. While HRSA can provide 

information on the geographic distribution of health center grantees, it 

does not have reliable information on the number and geographic 

distribution of delivery sites where the centers provide care. In its budget 

documents and performance reports, HRSA has used the number of 

delivery sites it funds to provide information on its progress toward 
Page 4 GAO-05-645 Health Centers

achieving its health center program goal of increasing the number of health 

center access points. Although HRSA mostly uses delivery site data from its 

Uniform Data System (UDS), the program’s administrative data set, to 

measure this progress, the agency is not confident that grantees accurately 

report to UDS the sites supported by program dollars. In addition, HRSA 

has underestimated the number of delivery sites it funded in fiscal years 

2002 through 2004 by counting each new access point grant as a single 

delivery site regardless of how many sites the grant supports. It is 

important for HRSA to ensure that it is collecting and reporting accurate 

and complete information about the number and location of delivery sites 

where health centers are providing care. HRSA officials and the Congress 

need this information to make decisions about managing and funding the 

health centers program.

HRSA has increased the role of performance measurement in its 

monitoring of health centers and has improved its collection of data that 

could help measure overall program performance. In 2004, the agency 

began to use a new process for on-site monitoring of individual health 

centers that focuses on each center’s performance on measures tailored to 

the specific needs of its community and patient population. The new 

review also provides specific feedback to each health center on ways to 

improve its performance. However, the new review generally does not 

provide standardized performance information that HRSA can use to 

evaluate the health center program as a whole. The agency is using other 

tools to collect data that could help measure overall program performance. 

For example, HRSA is collecting patient-level health outcome data through 

its Sentinel Centers Network—a network of health centers designed to be 

geographically and sociodemographically representative—and through its 

Health Disparities Collaboratives, which collect standardized data on 

patients with chronic diseases such as diabetes and asthma. Continued 

attention to such efforts could improve the agency’s ability to evaluate its 

success in improving the health of people in underserved communities. In 

addition to developing these data collection tools, HRSA has taken steps to 

improve the accuracy and completeness of UDS, which it uses to monitor 

aspects of the health centers’ operations and performance. For example, to 

improve the accuracy of UDS data on health centers’ delivery sites, for 

2004, HRSA revised the instructions to health center grantees for 

identifying their delivery sites. In providing this new guidance, HRSA has 

taken a step toward improving the quality of its information on the number 

and location of the delivery sites it funds. However, the agency will need to 

carefully assess the effectiveness of the guidance and, if necessary, take 

additional steps to ensure that delivery site information is accurate. 
Page 5 GAO-05-645 Health Centers

Although Consolidated Health Centers program funding has enabled health 

centers to expand the availability of primary care services, health centers 

often face difficulty ensuring that patients receive the specialty care they 

need. About one-third of health centers provide some specialty care on site, 

but health centers more often provide referrals to specialty care outside the 

center. Officials from most of the health centers in our review told us that 

there was a shortage of certain types of specialists available to receive 

referrals and some specialists were not willing to provide free care for 

uninsured patients.

We are recommending that the Administrator of HRSA ensure that the 

agency collects reliable information from grantees on the number and 

location of delivery sites funded through the program and accurately 

reports this information to the Congress.

In commenting on a draft of this report, HRSA acknowledged that more 

accurate and timely delivery site data would allow for improved 

management of the Consolidated Health Centers program and said that the 

agency has efforts under way to increase the accuracy of these data. HRSA 

did not indicate whether it plans to revise its method of counting delivery 

sites for its future reports on the progress of the health centers program to 

include all delivery sites funded since the President’s Health Centers 

Initiative began. We believe that it is important for HRSA and the Congress 

to have complete and accurate information on all delivery sites funded by 

program dollars. 

Background The Consolidated Health Centers program is administered by HRSA’s 

Bureau of Primary Health Care (BPHC). In addition to program grants from 

HRSA, which constitute about one-quarter of the centers’ budgets, the 

health centers receive funding from a variety of other sources, including 

Medicaid and state and local grants and contracts. (See fig. 1.) In 2003, 

health centers reported total revenues of about $5.96 billion. 
Page 6 GAO-05-645 Health Centers

Figure 1: Health Centers’ Sources of Revenue, 2003

Note: Percentages do not total to 100 percent due to rounding. Health centers reported total revenues 

of about $5.96 billion in 2003.

a

Other grants administered by BPHC account for 1 percent of health center revenue and include grants 

for capital improvement and management information systems.

b

Includes private third-party insurance (6 percent) and other public insurance (3 percent).

c

Includes funding from other federal grants (3 percent), indigent care programs (4 percent), and 

nonpatient-related funding not reported elsewhere (3 percent).

d

State and local grants and contracts account for 9 percent and private grants and contracts, including 

foundations, account for 3 percent. Percentages do not total to 13 percent due to rounding.

Health centers are required by law to serve a federally designated medically 

underserved area or a federally designated medically underserved 

population.7

 In 2003, 69 percent of health center patients had a family 

income at or below the federal poverty level, and 39 percent were 

uninsured. In addition, 64 percent of patients were members of racial or 

7

42 U.S.C. § 254b(a). Criteria for designating a medically underserved area or population 

include the ratio of primary medical care physicians per 1,000 population, infant mortality 

rate, percentage of the population with incomes below the federal poverty level, and 

percentage of the population age 65 or older. In 2004, the federal poverty level for a family of 

four was an annual income of $18,850 in the 48 contiguous states and the District of 

Columbia.

Medicaid

36%

22%

6% Medicare

State, local, and private grants and 

contractsd

13%

Other insuranceb 9%

Payments directly from patients 

6%

10%

Consolidated Health Centers program 

and other BPHC grantsa

Other revenuec

Source: GAO analysis of HRSA’s UDS, Calendar Year 2003 Data: National Rollup Report, Exhibit A.
Page 7 GAO-05-645 Health Centers

ethnic minority populations, and 30 percent spoke a primary language 

other than English.8

Health Center Organization 

and Services

Health centers are private, nonprofit community-based organizations or, 

less commonly, public organizations such as public health department 

clinics. The centers are typically managed by an executive director, a 

financial officer, and a clinical director. In addition, health centers are 

required by law to have a governing board, the majority of whose members 

must be patients of the health center.9,10

Health centers are required to provide a comprehensive set of primary 

health care services, which include treatment and consultative services, 

diagnostic laboratory and radiology services, emergency medical services, 

preventive dental services, immunizations, and prenatal and postpartum 

care. Centers are also required to provide referrals for specialty care and 

substance abuse and mental health services, and although centers may use 

program funds to provide such services themselves or to reimburse other 

providers, they are not required to do so. In addition, a distinguishing 

feature of health centers is that they are required to provide enabling 

services that facilitate access to care, such as case management, 

translation, and transportation. The health care services are provided by 

clinical staff—including physicians, nurses, dentists, and mental health and 

8

Information on health center patients is based on UDS data. The percentages related to 

income level and race/ethnicity exclude patients whose status HRSA reported as unknown. 

The income level of 20 percent of patients was reported as unknown, and the race/ethnicity 

of 6 percent of patients was reported as unknown.

9

42 U.S.C. § 254b(k)(3)(H). According to the health centers statute, HRSA must waive the 

governing board composition requirement for a center that proposes to serve homeless, 

migrant, or public housing populations exclusively and for those that are located in sparsely 

populated rural areas if the center can show “good cause” for the waiver. HRSA’s application 

guidance indicates that a waiver will be granted only if applicants show they cannot meet 

the composition requirement and that arrangements are in place to ensure appropriate 

patient input and involvement. HRSA program guidance indicates that a legal guardian of a 

patient who is a dependent child or adult, or a legal sponsor of an immigrant, may also be 

considered a patient for purposes of board representation.

10HRSA and some health center officials we interviewed believe patient representation on 

the governing board is key to identifying the health care needs of the community. Several 

representatives from health centers that do not receive Consolidated Health Centers 

program funding told us that the governing board requirement for majority patient 

representation deters some potential applicants for program funding because of concerns 

that the requirement could limit the financial and managerial expertise of the board. 
Page 8 GAO-05-645 Health Centers

substance abuse professionals—or through contracts or cooperative 

arrangements with other providers. Health center services are offered at 

one or more delivery sites and are required to be available to all people in 

the center’s service area.11 Services must be provided regardless of 

patients’ ability to pay.12 Uninsured users are charged for services based on 

a sliding fee schedule that takes into account their income level, and health 

centers seek reimbursement from public or private insurers for patients 

with health insurance.

HRSA’s Award Process for 

Grants Funded through the 

Consolidated Health 

Centers Program

HRSA uses a competitive process to award grants to health centers. Grant 

applications undergo an initial review for eligibility in which HRSA screens 

applications based on specific criteria—the applicant must be a public or 

private nonprofit entity, the applicant must be applying for an appropriate 

grant (e.g., certain grants funded by the program are available only to 

existing grantees), and the application must include the correct documents 

and meet page limitations and format requirements.13 Independent 

reviewers who have expertise in the health center program are selected by 

HRSA to review and score all eligible applications. The reviewers score an 

application by assessing each component of the applicant’s proposal, 

including descriptions of the need for health care services in the applicant’s 

proposed service area, how the applicant would integrate services with 

other efforts in the community, and the applicant’s capacity and readiness 

to initiate the proposed services. The Administrator of HRSA makes final 

award decisions and is required to take into account whether a center is 

located in a sparsely populated rural area, the urban/rural distribution of 

grants, and the distribution of funds across types of health centers 

(community, homeless, migrant, and public housing).14 In addition, the 

Administrator of HRSA also considers geographic distribution in making 

award decisions. The scope of a health center’s grant is delineated in its 

application and consists of its services, sites, providers, target population, 

1142 U.S.C. § 254b(a)(1). The requirement to serve all people in the center’s service area does 

not apply to centers that are specifically funded to serve homeless people, migratory and 

seasonal agricultural workers, or residents of public housing. 42 U.S.C. § 254b(a)(2).

1242 U.S.C. § 254b(k)(3)(G)(iii).

13HRSA officials told us that, in general, fewer than 10 percent of applications are deemed 

ineligible.

1442 U.S.C. § 254b(p), (k)(4), (r)(2)(B). 
Page 9 GAO-05-645 Health Centers

and service area. (See app. II for additional information on HRSA’s process 

for awarding health center grants.)

BPHC administers several competitive grants under the Consolidated 

Health Centers program, including new access point, expanded medical 

capacity, service expansion, and service area competition grants. (See table 

1.) HRSA approves funding for a specific project period—which can be up 

to 5 years for existing grantees and up to 3 years for new organizations—

and provides funds for the first year. For subsequent years, health centers 

must obtain funding annually through a noncompeting continuation grant 

application process in which the grantee must demonstrate that it has 

made satisfactory progress in providing services. A grantee’s continued 

receipt of grant funds also depends on the availability of funding.

Table 1: Description of Competitive Grants Funded through the Consolidated Health Centers Program

Source: GAO analysis of HRSA documents.

Type of grant Purpose Eligibility

Maximum annual funding for each 

awarded grant in fiscal year 2004

New access point To fund additional delivery sites that offer 

comprehensive primary and preventive 

health care services 

Existing grantees and 

organizations that 

currently do not receive 

program funding

$650,000

Expanded medical 

capacity

To increase the number of people served 

in a health center’s existing service area 

by expanding the capacity of existing 

sites, such as by increasing the number of 

medical providers, expanding hours of 

operation, expanding existing services, or 

adding new types of services through 

contractual relationships

Existing grantees $600,000

Service expansion To create and expand access to mental 

health, substance abuse, and oral health 

care services

Existing grantees $250,000 (oral health—new access)

$160,000 (mental health/substance 

abuse—new access)

$150,000 (oral health and mental 

health/substance abuse—expanded 

access)

Service area 

competition

To open competition for existing service 

areas when a health center’s project 

period is about to expire 

Existing grantees and 

organizations that 

currently do not receive 

program funding

The maximum level of support is not 

expected to exceed the previous annual 

level of program funding for this area or 

population
Page 10 GAO-05-645 Health Centers

HRSA’s Monitoring of the 

Consolidated Health 

Centers Program

To monitor health centers’ performance and compliance with federal 

statutes, regulations, and policies, HRSA relies on periodic on-site 

monitoring reviews, as well as ongoing monitoring. Through early 2004, 

HRSA used BPHC’s Primary Care Effectiveness Review (PCER) to provide 

periodic on-site monitoring of health center operations. The PCER was 

scheduled to occur every 3 to 5 years as a mandatory part of the 

competitive grant renewal process when a health center’s project period 

was about to expire. During on-site PCER visits, a team of reviewers 

identified strengths and weaknesses in health center administration, 

governance, clinical and fiscal operations, and management information 

systems. According to HRSA officials, review team members were 

generally not HRSA staff, but contractors. The last PCER review was 

conducted in March 2004.

HRSA created a new process for the periodic on-site review of all agency 

grantees, including health centers, and reviewers from HRSA’s Office of 

Performance Review (OPR) began to use this new process in May 2004. 

OPR reviews grantees in the middle of their project period—in the second 

year for new grantees and in the third or fourth year for existing grantees. 

According to HRSA officials, a goal of the OPR performance review 

process is to reduce the burden on grantees by consolidating the on-site 

monitoring of all HRSA grants to a health center into one comprehensive 

review. For example, if a health center receives a Ryan White Title III HIV 

Early Intervention grant,15 the OPR performance review covers both the 

Ryan White grant and the Consolidated Health Centers program grant(s). 

Each health center review team has three or four reviewers; HRSA’s goal is 

for the reviewers to be OPR staff, who are located in HRSA’s regional 

offices, with contractors being used to supplement OPR staff only when 

necessary. For each health center review, the review team prepares a 

performance report describing its findings. As necessary, the report 

identifies the health center’s technical assistance needs and actions the 

center needs to take to ensure its compliance with program requirements.

HRSA also conducts ongoing monitoring of health centers through its 

project officers, who serve as grantees’ main point of contact with the 

agency. Project officers use various tools to monitor compliance with 

program requirements and to assess the overall condition of health centers. 

For example, project officers review annual noncompeting continuation 

1542 U.S.C. §§ 300ff-51 through 300ff-78.
Page 11 GAO-05-645 Health Centers

grant applications, conduct midyear assessments, and regularly examine 

available data, including financial audits and UDS data. They are also 

expected to have regular contact with health centers by telephone and 

through e-mail and to connect grantees to resources for assistance when 

necessary, such as referring a health center to a HRSA-funded contractor 

for technical assistance to improve health center operations. In July 2003, 

HRSA transferred project officer responsibilities from its 10 regional 

offices and centralized this function within BPHC to improve the 

consistency of program oversight.

In addition, about one-third of the health centers funded under the 

Consolidated Health Centers program are accredited by the Joint 

Commission on Accreditation of Healthcare Organizations (JCAHO) and 

receive additional periodic on-site monitoring.16 These reviews include an 

assessment of a health center’s compliance with program laws and 

regulations, clinical procedures, and organizational processes, such as 

performance improvement activities and human resource management. 

HRSA began promoting accreditation for health centers in 1996, and under 

its current agreement with JCAHO, HRSA pays the fees for health center 

surveys,17 reducing the financial burden of accreditation for health centers. 

HRSA also provides financial support to the National Association of 

Community Health Centers to encourage accreditation and educate health 

centers about its benefits.

HRSA uses UDS data to monitor aspects of health center and overall 

program performance. Each year, health centers are required to report 

administrative data on their operations through UDS. These data include a 

list of each center’s service delivery sites and information about the 

center’s patients (e.g., race/ethnicity, insurance status); revenues; 

expenses; and service, staffing, and utilization patterns. HRSA uses UDS 

data to prepare its annual National Rollup Report, which summarizes the 

Consolidated Health Centers program; to prepare Comparison Reports, 

which allow the centers to compare their performance on certain measures 

16JCAHO is a not-for-profit organization that evaluates and accredits more than 15,000 health 

care organizations and programs in the United States using its own standards for the quality 

and safety of care provided by health care providers, including hospitals, ambulatory care 

providers, nursing homes, and home care organizations.

17The surveys include an initial survey, subsequent triennial surveys, and, as necessary, 

laboratory accreditation and behavioral health surveys.
Page 12 GAO-05-645 Health Centers

(e.g., productivity, cost per encounter) against that of other centers; and to 

generate analyses that HRSA uses when evaluating the program.

In March 2000, we reported on HRSA’s monitoring of the Consolidated 

Health Centers program.18 We analyzed UDS data from 1996 through 1998 

and noted deficiencies in data completeness and quality. Specifically, some 

grantees failed to report certain data elements or reported them very late, 

resulting in missing data. Furthermore, we found that the data editing and 

cleaning processes that were in place at the time did not always correct 

data errors that they were designed to detect. We recommended that HRSA 

improve the quality of UDS data and enforce the requirement that every 

grantee report complete and accurate data. In response to the 

recommendation, HRSA reported that a new requirement was in place for 

grantees to submit their UDS reports electronically, which improved the 

timeliness and accuracy of data by eliminating the need for a second level 

of data entry. In addition, the agency implemented formal training for 

centers on how to report UDS data.

Competition for Health 

Center Funding Has 

Increased, and HRSA Is 

Evaluating Its Process 

for Assessing Need

Competition for new access point, expanded medical capacity, and service 

expansion grants increased during the first 3 years of the President’s Health 

Centers Initiative. For example, while HRSA funding of new access point 

grants decreased by about half from fiscal year 2002 to fiscal year 2004, the 

number of applicants rose by 28 percent. HRSA is concerned that its 

current process for awarding new access point grants may not be 

consistent with the goal of funding health centers in the neediest 

communities. Therefore, the agency is considering both revising the 

measures it uses to assess need and increasing the relative weight of need 

in the award process. 

18GAO, Community Health Centers: Adapting to Changing Health Care Environment Key 

to Continued Success, GAO/HEHS-00-39 (Washington, D.C.: Mar. 10, 2000). This report 

focused only on community and migrant health centers.
Page 13 GAO-05-645 Health Centers

Funding for Grants to 

Increase Health Center 

Services Has Become More 

Competitive Since the 

President’s Health Centers 

Initiative Began

Competition for new access point grants increased over the first 3 years of 

the President’s Health Centers Initiative. Although the majority of grant 

funds are awarded for continuation grants, for which funding increased, 

funding for other types of grants declined. (See fig. 2.) For example, 

funding for new access point grants decreased from about $80 million in 

fiscal year 2002 to about $38 million in fiscal year 2004, a 53 percent 

decline. 

Figure 2: Allocation of Consolidated Health Centers Program Funding, by Type of 

Grant, Fiscal Years 2002 through 2004 

a

Continuation grants are noncompeting continuation grants and service area competition grants. 

b

Base adjustments are supplemental funding that HRSA awards to existing grantees to help offset 

rising costs.

0

300

600

900

1,200

1,500

Dollars in millions

1,195

1,315

1,409

 2002 2003 2004

Type of grant 

New access point $80 $53 $38

Expanded medical capacity 56 39 19

Service expansion 27 13 9

Continuationa 1,032 1,175 1,318

Base adjustmentb 0 35 25

Total $1,195 $1,315 $1,409

Source: GAO analysis of HRSA data.
Page 14 GAO-05-645 Health Centers

At the same time, the number of eligible new access point applications 

increased by 28 percent. Combined with the decrease in new access point 

funding, this resulted in a decrease in the proportion of applicants that 

HRSA funded—from 52 percent of fiscal year 2002 applicants to 20 percent 

of fiscal year 2004 applicants. Some of these applicants received funding in 

the same year they applied, and others received funding the following 

year.19 (See fig. 3.) The percentage of new access point applicants HRSA 

funded in the same year they applied decreased from 43 percent in fiscal 

year 2002 to 3 percent in fiscal year 2004. In addition, HRSA approved 

17 percent of the applications it received in fiscal year 2004 for funding in 

fiscal year 2005. 

19HRSA officials told us that awards to be funded in the following year are contingent on the 

availability of funds at that time. 
Page 15 GAO-05-645 Health Centers

Figure 3: Disposition of Applications, by Type, Fiscal Years 2002 through 2004

Note: Eligible applications meet the following criteria: the applicant is a public or private nonprofit entity, 

the applicant is applying for an appropriate grant (e.g., expanded medical capacity and service 

expansion grants are available only to existing grantees), and the application includes the correct 

documents and meets page limitations and format requirements. 

Competition for expanded medical capacity and service expansion grants 

also increased during the President’s Health Centers Initiative. Funding for 

expanded medical capacity grants decreased from about $56 million in 

fiscal year 2002 to about $19 million in fiscal year 2004, and funding for 

service expansion grants decreased from about $27 million in fiscal year 

2002 to about $9 million in fiscal year 2004. With the decrease in funding 

amounts, the percentage of funded applicants also decreased. HRSA 

funded 66 percent of fiscal year 2002 expanded medical capacity applicants

Next

Next

Next

Next

Next

 2002 2003 2004 2002 2003 2004 2002 2003 2004

Eligible applications funded 

in the current fiscal year 152 67 15 131 67 66 160 125 79

Eligible applications funded 

in the next fiscal year 33 48 76 21 0 0 0 0 0

Eligible applications 

not funded 171 281 363 80 106 127 121 286 290

Total applications 356 396 454 232 173 193 281 411 369

Source: GAO analysis of HRSA data.

New 

access point

Expanded 

medical capacity

Service 

expansion

Applications

0

100

200

300

400

500
Page 16 GAO-05-645 Health Centers

and 57 percent of fiscal year 2002 service expansion applicants;20 in fiscal 

year 2004, it funded 34 percent and 21 percent of the applicants, 

respectively. 

Although HRSA funded fewer grants to increase health center services 

during the second and third years of the President’s Health Centers 

Initiative, HRSA officials believe program funding for fiscal year 2005 and 

the President’s proposed budget for fiscal year 2006 will allow them to 

exceed the initiative’s goal.21 From fiscal year 2002 through fiscal year 2004, 

HRSA funded 334 new access point grants and 285 expanded medical 

capacity grants, representing about half of the initiative’s 5-year goal of 

providing 630 new access point grants and 570 expanded medical capacity 

grants. 

HRSA’s Process for 

Assessing Need for New 

Access Point Grants Has 

Changed

The process HRSA uses to assess the need for services in a new access 

point applicant’s proposed service area has changed since the beginning of 

the President’s Health Centers Initiative. In fiscal year 2002, new access 

point applicants were ranked according to both the score they received on 

a need-for-assistance worksheet22 and the score assigned by independent 

reviewers after they evaluated the technical merit of the application. In 

fiscal years 2003, 2004, and 2005, however, HRSA did not use the worksheet 

scores to rank applicants. Instead, it used the worksheet scores to screen 

applicants; only applicants that scored 70 or higher on the worksheet had 

their application forwarded to independent reviewers for an evaluation of 

its technical merit. In addition to changing the role of the need-forassistance worksheet score, HRSA also increased the relative weight of the 

need criterion in the application score. In fiscal year 2002, the maximum 

20Nine percent of the fiscal year 2002 expanded medical capacity applicants received their 

funding in fiscal year 2003.

21Estimated federal funding for the Consolidated Health Centers program was about $1.69 

billion in fiscal year 2005. The President’s proposed budget for fiscal year 2006 allocated 

about $1.99 billion to the program. 

22HRSA uses the need-for-assistance worksheet to measure barriers to obtaining care and to 

measure health disparity factors in the applicant’s proposed service area. Barriers to care 

include the distance or time to the nearest primary care provider and percentage of the 

population age 5 years or older who speak a language other than English. Health disparity 

factors include the rates of specific diseases and health outcomes, such as cancer, infant 

mortality, low-birth-weight infants, and teen pregnancy. Applicants can score up to 100 

points on the worksheet. 
Page 17 GAO-05-645 Health Centers

need criterion score constituted 5 percent of the maximum total 

application score; in fiscal years 2003, 2004, and 2005, the maximum need 

criterion score constituted 10 percent of the maximum total score. 

HRSA has raised concerns that its current process for assessing the need 

for services in a new access point applicant’s proposed service area may 

not be consistent with the goal of the President’s Health Centers Initiative 

to fund health centers in the neediest communities. HRSA reported that the 

process had resulted in little distinction among applicants’ need-forassistance worksheet scores and that almost all applicants received a score 

of 70 or higher. During the first 3 years of the President’s Health Centers 

Initiative, only 24 of 1,346 applications scored lower than 70 points. In 

addition, HRSA reported that the relative weight assigned to an applicant’s 

description of the need for health care in its proposed service area

(10 percent) might be too low. In light of these concerns, HRSA 

commissioned a study to evaluate whether the measures in the need-forassistance worksheet reflected the relative need of different applicants and 

whether the review criteria were weighted appropriately to ensure that 

grants were awarded to the neediest communities. The report, which was 

issued in November 2003, recommended several changes, including 

revising measures in the need-for-assistance worksheet and increasing the 

maximum need score from 10 percent to 20 percent of the maximum total 

score.23

In response to these recommendations and feedback from program 

applicants, HRSA is considering revising the method it uses to assess the 

need for services in new access point applicants’ service areas. On 

February 4, 2005, HRSA issued a Federal Register notice seeking 

comments on a proposal to change the measures used in the need-forassistance worksheet and to substitute the need-for-assistance worksheet 

for the current need criterion in the grant application.24 HRSA also sought 

comments on what weight the agency should give need in the application 

score. Comments on the Federal Register notice were due on March 7, 

23Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel 

Hill and Health Systems Research, Inc., Evaluation of Need for Assistance Criteria and 

Weighting of Overall Criteria in the Requirements of Funding New Start and Expansion 

Grant Applications for Health Centers, report prepared at the request of HRSA, November 

2003.

24Development of Revised Need for Assistance Criteria for Assessing Community Need for 

Comprehensive Primary and Preventive Health Care Services under the President’s Health 

Centers Initiative, 70 Fed. Reg. 6016-6023 (Feb. 4, 2005). 
Page 18 GAO-05-645 Health Centers

2005, and HRSA expected to complete its analysis by June 2005. HRSA 

reported it would delay the May 23, 2005, due date for new access point 

applications until its analysis was complete.25

To further strengthen its ability to award new access point grants in the 

neediest communities, HRSA has indicated that it may focus its efforts on 

high-poverty counties without a health center delivery site.26 In its fiscal 

year 2006 budget justification, HRSA noted that, without special attention 

to high-poverty counties, the current award process may result in some of 

these counties not having a health center site. For example, it may be 

difficult for an applicant in a high-poverty county to demonstrate its 

financial viability. In the budget justification, HRSA requested funds 

specifically for awarding new access point grants to centers serving highpoverty counties and planning grants to community-based organizations to 

support the establishment of centers in such counties.

Number of New Access 

Point Grantees Varies 

Widely by State, but 

HRSA Lacks Reliable 

Information on 

Delivery Sites 

The number of health centers receiving new access point grants varied 

widely by state during the first 3 years of the President’s Health Centers 

Initiative.27 During that period, HRSA awarded 334 new access point 

grants,28 with at least one grantee in each state.29 About half of the grantees 

were in 10 states—Alaska, California, Illinois, Massachusetts, New Mexico, 

New York, Oregon, South Carolina, Texas, and Virginia. The number of 

grantees in each state ranged from 57 in California to 1 each in Delaware, 

the District of Columbia, Kansas, and Wyoming. (See app. III for additional 

information on the number of new access point grants by state and 

territory. See app. IV for the numbers of all health center grantees, by state 

and territory, operating in 2001—before the initiative began—and in 2003—

the most recent year for which data were available at the time we 

conducted our review. Figure 4 shows the location of health centers that 

HRSA was funding in 2003.) 

25May 23, 2005, was the due date for the second round of fiscal year 2005 new access point 

applications. December 1, 2004, was the due date for the first round of applications. 

26HRSA officials said the agency has not yet determined what constitutes a high-poverty 

county. 

27Unless otherwise noted, in this report, “states” refers to the 50 states and the District of 

Columbia. 

28About half of the grants went to health centers that were new to the program, and about 

half went to health centers already in the program that were adding to their delivery sites. 

29HRSA also funded grants in American Samoa, Puerto Rico, and the Virgin Islands. 
Page 19 GAO-05-645 Health Centers

Figure 4: Health Center Grantees Funded through the Consolidated Health Centers Program, 2003 

Note: The map depicts 863 health center grantees in the 50 states and the District of Columbia that 

submitted data to the 2003 UDS; 27 grantees in the territories also submitted data to the 2003 UDS. 

HRSA was funding an additional 9 grantees in 2003, but 7 of these grantees were not required to 

report to the 2003 UDS because they either did not operate for more than 90 days in 2003 or merged 

with another grantee. The other 2 grantees were required to report, but did not submit data. The map 

indicates a single location for each health center grantee. However, grantees provided services at one 

or more delivery sites.

Source: GAO analysis of 2003 UDS data.

Health center locations by zip code

• 2 health centers

• 1 health center
Page 20 GAO-05-645 Health Centers

In 2003, the distribution of all health center grantees was 48 percent urban 

and 52 percent rural.30 HRSA is required by law to make awards so that 40 

to 60 percent of patients expected to be served reside in rural areas.31

HRSA officials told us that the agency meets this requirement by ensuring 

that the proportion of awards to rural health centers is from 40 to 60 

percent. Based on the numbers of patients reported by health centers to the 

UDS, the proportion of patients served by urban health centers in 2003 was 

54 percent and the proportion served by rural centers was 46 percent. 

While HRSA can provide information on the geographic distribution of 

health center grantees, it does not have reliable information on the number 

and geographic distribution of the delivery sites where the centers provide 

care. In its budget justification documents and Government Performance 

and Results Act reports, HRSA has used the number of delivery sites it 

funds to provide information on its progress toward achieving its goals for 

the Consolidated Health Centers program. For example, in its fiscal year 

2005 performance plan, HRSA has a performance goal of increasing access 

points in the health centers program, and it used 2001 UDS data on the 

number of health center delivery sites as a baseline to measure progress 

toward this goal. HRSA, however, is not confident that UDS data accurately 

reflect the number of sites supported by program dollars. HRSA officials 

told us that the agency does not verify the accuracy of the delivery site 

information grantees provide to UDS. They also said that UDS delivery site 

data through 2003 may include sites not funded by the health centers 

program and sites that HRSA did not approve in the scope of a health 

center’s grant. Moreover, HRSA has been reporting inconsistent data on the 

number of health center delivery sites in the program. For example, in its 

fiscal year 2005 performance plan, HRSA reported funding 3,588 delivery 

sites in fiscal year 2003, consisting of 3,317 delivery sites operating in fiscal 

year 2001 and 271 new access point grants funded in fiscal years 2002 and 

30The urban/rural designation is self-reported by health centers in their grant application. 

HRSA instructs health centers to classify themselves as urban or rural based on where the 

majority of their patients reside. For example, if a health center is located in an urban area, 

but more than 50 percent of its patients reside in rural areas, the center should classify itself 

as rural. 

3142 U.S.C. § 254b(k)(4). This requirement has applied to all types of health centers since the 

programs were consolidated in 1996. Health Centers Consolidation Act of 1996, Pub. L. No. 

104-299, sec. 2, § 330(k)(4), 110 Stat. 3626, 3639 (1996). Prior to the consolidation, this 

requirement applied only to community health centers, and it was added to their authorizing 

legislation by the Health Services and Centers Amendments of 1978, Pub. L. No. 95-626, § 

104(d)(5)(B), 92 Stat. 3551, 3557-58 (1978).
Page 21 GAO-05-645 Health Centers

2003; however, some of the new access point grants represent more than 

one delivery site. As a result, HRSA underestimated the number of new 

program delivery sites operating in fiscal years 2002 and 2003.

HRSA Has Increased 

the Role of 

Performance 

Measurement in 

Monitoring and 

Improved Its 

Collection of Health 

Center Data 

HRSA’s new tool for periodic on-site review of health centers—the OPR 

performance review—focuses on monitoring individual health centers’ 

performance on selected measures, including health outcome measures. 

The OPR performance review generally does not provide HRSA with 

standardized performance information for evaluating the Consolidated 

Health Centers program as a whole. However, the agency is using other 

data collection tools, such as its Sentinel Centers Network, that could help 

it measure overall program performance. HRSA also uses UDS to monitor 

aspects of health centers’ performance, and the agency has taken steps to 

improve the accuracy and completeness of that data set.

HRSA’s New Process for 

Monitoring Health Centers 

and Other Data Collection 

Tools Include Patient Health 

Outcome Measures

HRSA’s new health center reviews, conducted by OPR staff, focus on 

evaluating selected measures of performance and identifying ways to 

improve health centers’ operations and performance.32 OPR works with 

each health center to select three to five measures that reflect the specific 

needs of the center’s community and patient population, and then to 

ascertain the health center’s current performance on each measure.33,34 For 

the health centers we contacted that had undergone the OPR performance 

review,35 most of the measures were health outcome measures. These 

measures included the average number of days that asthmatic patients are 

symptom free, percentage of patients age 60 or older receiving influenza 

and pneumonia immunizations, and percentage of low-birth-weight infants 

32As of February 2005, 100 health center reviews had been conducted; an additional 220 

reviews were scheduled to be conducted in 2005.

33If the health center receives grants from other HRSA programs, additional measures are 

selected for those grant programs. 

34HRSA officials told us that, beginning in January 2005, all health center reviews began to 

include the number of patients receiving care as one measure. They said the agency is 

exploring the use of additional measures that would be included in all health center reviews 

starting in 2006. 

35In addition to our interviews of officials from 12 health centers, we also interviewed 

officials from 6 other health centers that had completed an OPR performance review.
Page 22 GAO-05-645 Health Centers

born to health center patients.36 Health centers may set performance goals 

related to these measures. For example, one health center adopted the goal 

set by Healthy People 2010 of reducing the percentage of low-birth-weight 

infants born to its patients to less than 5 percent.37 HRSA officials told us 

that the agency intends to follow up annually on grantees’ performance on 

these measures. When possible, HRSA plans to track progress using data 

the grantee already reports. For example, HRSA would be able to use UDS 

data to track progress on the number of health center patients receiving 

care. HRSA officials told us that because the OPR performance reviews 

began recently, the agency is still determining how it will track 

performance on other measures, including many related to patient health 

outcomes.

After assessing the health center’s performance on each measure, the 

review team analyzes the factors that contribute to and hinder the center’s 

performance on these measures, including the processes and systems the 

health center uses in its operations. During an on-site visit, the review team 

meets with health center staff to discuss these factors and determine which 

are the most important to address. The review team also identifies 

potential actions that could help the center improve its performance and 

identifies possible partners in making improvements. For example, to 

improve one health center’s performance on its low-birth-weight measure, 

the review team suggested the center undertake provider and patient 

education, training for health center staff, continued partnerships with 

other service providers and community groups, and an analysis of patient 

medical charts to identify the risk factors of patients who gave birth to lowbirth-weight infants.

HRSA requires that grantees develop an action plan to improve 

performance in response to the review team’s findings. The action plan 

describes the specific steps the grantee plans to take to improve 

performance on each measure and provides estimated completion dates. 

For example, the health center discussed above proposed hiring an outside 

physician to conduct chart reviews and showing a video on cultural 

competence to all staff as two specific actions to improve performance on 

its low-birth-weight measure. 

36Other measures selected by health centers related to the number of health center patients 

receiving care, accuracy of data, and the financial condition of the health center.

37HHS’s Healthy People 2010 is a set of health promotion and disease prevention objectives 

for the nation to achieve by 2010. 
Page 23 GAO-05-645 Health Centers

While the OPR review primarily focuses on health centers’ performance on 

specific measures, the reviews also verify key aspects of health centers’ 

compliance with Consolidated Health Centers program requirements. The 

review teams examine information HRSA maintains on each health center, 

including grant applications and financial audits. According to HRSA 

officials, OPR reviewers also follow up on concerns identified by project 

officers, who are the agency’s primary means for ongoing monitoring of 

health center operations and compliance. If the review team identifies any 

instances of noncompliance with program requirements—such as those 

related to the types of services the center must provide and the 

composition of its governing board—HRSA requires grantees to address 

them in the action plan.

HRSA officials told us they hoped that in addition to providing information 

on individual health centers, the OPR performance reviews would result in 

information that could improve other centers’ services and operations. 

HRSA officials said that as reviewers gained more experience in evaluating 

health centers, they would be better able to identify best practices that 

contribute to outstanding patient health outcomes and share these 

practices among health centers. HRSA officials told us that OPR planned to 

use this information to develop a list of successful practices employed by 

health centers, such as a patient tracking system or prescription drug 

subsidy program. They said they expected to generate this list three times a 

year and to make it available as a resource for project officers and OPR 

review teams to share with other health centers.

The health center officials we interviewed whose centers had undergone 

the OPR performance review said that, in general, it provided helpful 

suggestions for improving services and operations.38 Officials from some 

health centers told us that they planned to incorporate the performance 

goals and their progress in achieving them into their future grant 

applications. Health center staff also described the reviews as accurate and 

thorough and said they appreciated the in-depth method of looking at 

performance in targeted areas. Officials from a few health centers also 

noted that their reviewers had expertise on the health centers program 

38Health center officials told us their center also used other tools and local data sources to 

measure performance and identify areas for improvement. Some of these tools included 

UDS data, county and community health assessments, patient surveys, patient health data, 

and the center’s governing board. For example, one official told us the center regularly 

compared its individual performance with federal and state disease and infant mortality 

rates. 
Page 24 GAO-05-645 Health Centers

because the reviewers had previously been project officers for the 

program; one health center official said that this expertise was critical to 

the review process. In many cases, HRSA field office staff conduct 

performance reviews of health centers in states or communities with which 

they are already familiar. HRSA officials told us this experience has 

allowed the OPR reviewers to understand performance in the context of 

the local, state, and regional environment, such as the effect state Medicaid 

funding and policy changes might have on the number of people receiving 

health center services.

While the OPR review evaluates the performance of individual health 

centers, it generally does not provide standardized performance 

information for the Consolidated Health Centers program as a whole, and 

HRSA is using other tools to collect information that could help measure 

overall program performance. In 2002, HRSA began collecting data on 

health centers’ services and patient populations through its Sentinel 

Centers Network—a network of health centers designed to be 

geographically and sociodemographically representative. As of February 

2005, 67 health centers, with more than 1 million patients, were 

participating in the network. Participating health centers report patient-, 

encounter-, and practitioner-level data.39 The network is intended to 

supplement HRSA’s other data sources, such as the Community Health 

Center User and Visit Survey,40 which is conducted only every 5 to 7 years, 

and the UDS, which generally provides grantee-level data. 

HRSA also collects information that could help it measure overall program 

performance through its Health Disparities Collaboratives, which the 

agency views as a tool for improving the quality of care. Participating 

health centers use a model for patient care that includes evidence-based 

practice guidelines. The model also includes a database in which the health 

centers collect standardized patient-level health outcome data that are 

used to track progress and are shared with all health centers in the

39Patient-level data elements include sex, ethnicity, race, education level, smoking status, 

weight, and blood pressure and cholesterol levels. Encounter-level data elements include 

the date the service was provided and procedure and diagnosis codes. Practitioner-level 

data elements include primary and secondary specialties and number of years the 

practitioner has been employed by the health center.

40The Community Health Center User and Visit Survey collects information from about 2,000 

health center patients about their health center experiences.
Page 25 GAO-05-645 Health Centers

collaborative.41 HRSA plans to expand the collaborative model from a focus 

on specific diseases to a focus on primary care in general. Through 2004, 

497 health centers had implemented the collaborative model for at least 

one disease. An additional 150 centers began the collaborative process in 

February 2005.42 In the future, HRSA officials would like to extend the 

model to all health centers in the Consolidated Health Centers program. 

HRSA has a contract with Johns Hopkins University for evaluating data 

from the Sentinel Centers Network and other health center data, such as 

UDS data.43 According to HRSA officials, the purpose of this contract is to 

provide timely, short-term statistical analyses and longer-term evaluation 

studies using databases that contain information on health centers. One 

planned study will examine preventive services provided by health centers, 

and several will focus on the role of health centers in reducing racial/ethnic 

and socioeconomic disparities in health outcomes for health center users. 

41In 1998, HRSA and the Institute for Healthcare Improvement (a private not-for-profit 

organization) developed the first Health Disparities Collaborative, which focused on 

diabetes care. Since that time, additional collaboratives have focused on asthma, 

depression, cardiovascular disease, and cancer. 

42Health centers participating in a Health Disparities Collaborative initially go through a 12-

month training period. Teams from the health centers attend learning sessions, test and 

implement changes in practice, and collect data to measure the impact of these changes on 

patient health outcomes in specific disease areas. HRSA’s service expansion grants have 

included awards to support health centers’ continued implementation of the collaborative 

model after the training period; 52 health centers in fiscal year 2003 and 32 health centers in 

fiscal year 2004 received, on average, about $40,000 each. HRSA officials told us that these 

grants are often used to support centers’ infrastructure, such as computer systems for data 

management.

43Past studies of the health center program that HRSA conducted with researchers from 

Johns Hopkins included a study that examined the role of health centers in reducing 

disparities in access to care and a study that examined the role of health centers in reducing 

ethnic disparities in perinatal care and birth outcomes. See Robert Politzer and others, 

“Inequality in America: The Contribution of Health Centers in Reducing and Eliminating 

Disparities in Access to Care,” Medical Care Research and Review, vol. 58, no. 2 (2001); and 

Leiyu Shi and others, “America’s Health Centers: Reducing Racial and Ethnic Disparities in 

Perinatal Care and Birth Outcomes,” Health Services Research, vol. 39, no. 6, Part I (2004). 

HRSA also has contracts with other organizations for evaluating health center data. For 

example, HRSA has contracts with researchers at Harvard Medical School and the 

University of Chicago Medical School to evaluate the effect of the collaboratives on patient 

care.
Page 26 GAO-05-645 Health Centers

HRSA Has Taken Actions to 

Improve the Completeness 

and Accuracy of Its Uniform 

Data System

Since our previous report on the health centers program in March 2000,44

HRSA has taken steps to improve the UDS data collection and reporting 

process by trying to ensure that all Consolidated Health Centers program 

grantees report to the system and that the information they report is 

complete and accurate. HRSA’s efforts resulted in near-universal 

reporting—99.8 percent—by grantees for 2003. HRSA contacts grantees 

that do not submit UDS data for the preceding calendar year by February 

15. HRSA officials told us that after they made several efforts to try to 

obtain UDS data, only 2 of the 892 grantees required to report in 2003 did 

not submit data.45

To minimize errors in the data set, HRSA implements data quality 

assurance procedures in the UDS data collection process. Specifically, 

HRSA has programmed 474 edit checks into the software that grantees use 

to report UDS data. These edit checks detect mathematical and logical 

errors and are triggered while grantees are entering or verifying data. 

Mathematical edit checks ensure that rows and columns sum to the total 

submitted by the grantee, and logical edit checks ensure consistency within 

and across tables. For example, one logical edit check ensures that the 

total number of patients reported by age and sex equals the total number of 

patients reported by race/ethnicity. The grantee is prompted to address 

inaccuracies or inconsistencies identified by the edit checks before 

submitting the data to HRSA.

When HRSA receives grantees’ UDS submissions, its contractor conducts 

additional edit checks. The contractor confirms that grantees’ submissions 

are substantially complete, which includes ensuring that tables are not 

blank, and forwards satisfactory submissions to an editor.46 The editors 

review the mathematical and logical checks triggered by the software and 

the checks for completeness conducted by the contractor. The editors also 

conduct 304 additional edit checks, which include comparisons to data 

submitted in the previous year and comparisons to industry norms. When 

they find an aberrant data element, editors contact grantees to determine if

44GAO/HEHS-00-39. 

45In 2003, all grantees that had been operating for more than 90 days were required to submit 

UDS data.

46When submissions are unsatisfactory, the contractor follows up with grantees to obtain 

missing data.
Page 27 GAO-05-645 Health Centers

there is an error in the data or if there is a reasonable explanation.47 If there 

is an error, the editor and grantee agree on a process and timeline for the 

grantee to submit corrected data, and the grantee’s UDS data are revised.48

HRSA officials told us that editors were experienced with UDS, the 

Consolidated Health Centers program, and data editing. The editors have 

also attended training to ensure consistency across editors and to learn 

about new edit checks. In addition, editors are assigned to grantees in a 

single state or region to facilitate their understanding of unique regional 

issues that could affect UDS data, such as managed care participation.

We found the UDS data for the selected data elements we evaluated to be 

generally accurate. For the mathematical and logical edit checks of 25 data 

elements we conducted, we found very few errors, and each error was due 

to missing data.49 In addition, we found no discrepancies in our replication 

of five analyses in HRSA’s 2003 National Rollup Report. 

To improve the accuracy of UDS data on the number and location of health 

center delivery sites, for 2004, HRSA revised the instructions to grantees 

for identifying their delivery sites. The new instructions specified that 

grantees should report delivery sites that provide services on a regularly 

scheduled basis and that are operated within the approved scope of the 

health center’s grant. HRSA also provided more detailed instructions to 

help grantees determine which delivery sites they should include in their 

UDS submission and which sites they should exclude. As of June 2005, 

HRSA had not validated the accuracy of the 2004 UDS data on delivery 

sites.

47HRSA officials said nearly all submissions generate at least one potential error that 

requires an editor to contact a grantee.

48If the editor is unable to obtain accurate data, the information is rated “questionable” and 

the editor documents the reason. 

49We conducted 25 edit checks for all 890 grantees reporting to UDS in 2003. For 16 of the 25 

checks, there were no missing data, 8 checks had missing data for 1 or 2 grantees, and 1 

check had missing data for 12 grantees. 
Page 28 GAO-05-645 Health Centers

Health Centers Often 

Face Challenges 

Securing Specialty 

Care for Patients 

In addition to providing comprehensive primary and preventive health care 

services, most health centers receiving Consolidated Health Centers 

program grants provide specialty care on site or have formal arrangements 

for referring patients to outside specialists for care. According to the 2003 

UDS data, 32 percent of health centers provided some specialty care on 

site.50 Specialists providing services on site include health center 

employees and volunteers. In addition, 83 percent of health centers 

reported that they had formal referral arrangements for some specialty 

care,51 which included agreements with community providers, such as local 

hospitals and networks of specialty care providers. Almost all of these 

health centers reported that they did not pay for some of the services for 

which they referred patients. In addition to formal referrals, health centers 

also informally refer patients to specialty care. Health center officials told 

us that many of their referrals for specialty care were arranged informally 

through discussions between health center staff and the specialty care 

provider,52 and specialists donated their time to provide services to the 

health center’s patients. 

Health center officials told us that obtaining specialty care for center 

patients, especially patients who are uninsured, could be difficult. Officials 

from most of the health centers in our review said that there was a shortage 

of certain specialists available to receive referrals from their health center. 

For example, one official told us that there were only two specialists 

providing gynecologic oncology services in the county, and both physicians 

were overbooked with paying patients. Health center officials told us that 

some specialists—such as orthopedists, neurologists, oncologists, 

cardiologists, ophthalmologists, and dermatologists—were difficult to find. 

50UDS defines specialty care as services provided by medical professionals trained in allergy, 

dermatology, gastroenterology, general surgery, neurology, optometry, ophthalmology, 

otolaryngology, pediatric specialties, and anesthesiology. UDS also collects data on other 

specialty care services—directly observed tuberculosis therapy (delivery of therapeutic 

tuberculosis medication under direct observation of health center staff) and respite care 

(recuperative or convalescent services used by people who are homeless and have medical 

problems but are too ill to recover on the streets or in a shelter)—and certain professional 

services, such as podiatry.

51A formal referral arrangement means the health center either had a written agreement with 

the specialty care provider or could document the service in the patient record. 

52In some cases, health centers referred patients to specialty care services beyond those 

included in UDS’s definition of specialty care, such as orthopedics, cardiology, oncology, 

and rheumatology.
Page 29 GAO-05-645 Health Centers

This problem is exacerbated because, according to officials from most of 

the health centers in our review, some specialists are not willing to provide 

free care for uninsured patients. As a result, there are often long waiting 

lists for health center patients to see a specialty care provider who is 

willing to provide donated services. For example, one health center official 

told us that a patient might have to wait 9 months for an appointment with 

a dermatologist. One health center official characterized the center’s 

efforts to secure specialty care for patients as “begging.” Although these 

issues present a problem for health centers in both urban and rural areas, 

people living in rural communities could face additional challenges 

affecting their access to care, such as a need to travel a long distance to 

obtain care.

Conclusions HRSA’s Consolidated Health Centers program has played a pivotal role in 

providing access to health care for people who are uninsured or who face 

other barriers to receiving needed care. When HRSA makes decisions 

about awarding program funds to support additional health center delivery 

sites, it is faced with the challenge of identifying applicants that will serve 

communities with a demonstrated need for services and that will operate 

centers that can effectively meet those needs and remain financially viable. 

HRSA has indicated that it is not confident that its award process for new 

access point grants—which is intended to meet this challenge—has 

sufficiently targeted communities with the greatest need. HRSA’s recent 

effort to evaluate the assessment and relative weight of need in the award 

process could result in greater confidence that the agency is appropriately 

considering community need in distributing federal resources to increase 

access to health care.

In light of the growing federal investment in health centers during the 

President’s Health Centers Initiative, it is important for HRSA to ensure 

that health centers are operating effectively and improving patient health 

outcomes. HRSA’s adoption of a performance monitoring process that 

includes emphasis on patient health outcomes and its efforts to collect 

health outcome data constitute an important step in improving the agency’s 

capacity to assess health centers and the health centers program. 

Continued attention to such efforts could improve HRSA’s ability to 

evaluate its success in improving the health of people in underserved 

communities. 

It is also important for HRSA to ensure that it is collecting and reporting 

accurate and complete information about the number and location of 
Page 30 GAO-05-645 Health Centers

delivery sites where health centers are providing care. In providing new 

UDS guidance to grantees, HRSA has taken a step toward improving the 

quality of its information on delivery sites. The agency will need to 

carefully assess the effectiveness of its new guidance and, if necessary, 

take additional steps to ensure that delivery site information is accurate. 

HRSA officials and the Congress need accurate and complete information 

on delivery sites to assess whether the health centers program is achieving 

its goal of expanding access to health care for underserved populations and 

to make decisions about managing and funding the program.

Recommendation for 

Executive Action

We recommend that, to provide federal policymakers and program 

managers with accurate and complete information on the Consolidated 

Health Centers program’s activities and progress toward its performance 

goals, the Administrator of HRSA ensure that the agency collects reliable 

information from grantees on the number and location of delivery sites 

funded by the program and accurately reports this information to the 

Congress.

Agency Comments We provided a draft of this report to HRSA for comment. HRSA 

acknowledged that more accurate and timely delivery site data would allow 

for improved management of the Consolidated Health Centers program and 

said that the agency already has efforts under way to increase the accuracy 

of delivery site data. (HRSA’s comments are reprinted in app. V.) HRSA 

stated that the accuracy of delivery site data does not affect its ability to 

assess and report the progress of the President’s Health Centers Initiative 

because it believes this progress is more appropriately assessed by the 

number of new access point and expanded medical capacity grants HRSA 

has awarded. While HRSA may choose to assess the progress of the 

President’s Health Centers Initiative on this basis, it is not appropriate to 

equate the number of new access point grants awarded to health centers 

with the number of delivery sites where these centers provide care. HRSA 

did not indicate whether it plans to revise its method of counting delivery 

sites for its future reports to the Congress to include all delivery sites 

funded since the President’s Health Centers Initiative began. We continue 

to believe it is important that HRSA collect and report accurate data on the 

number and location of all delivery sites funded by the program so that 

agency officials and the Congress will have the information they need to 

monitor the program’s progress in increasing access to health care and to 

make decisions about managing and funding the program. HRSA also 
Page 31 GAO-05-645 Health Centers

provided technical comments, and we revised our report to reflect the 

comments where appropriate. 

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 Health and Human Services, the Admiistrator of the Centers for 

Medicare & Medicaid Services, and other interested parties. We will also 

make copies available to others upon request. In addition, the report will be 

available at no charge on the GAO Web site at http://www.gao.gov.

If you or your staff have any questions about this report, please contact me 

at (202) 512-7119. Contact points for our Offices of Congressional Relations 

and Public Affairs may be found on the last page of this report. An 

additional contact and the names of other staff members who made 

contributions to this report are listed in appendix VI.

Sincerely yours,

Marjorie Kanof

Managing Director, Health Care
Page 32 GAO-05-645 Health Centers

Appendix I

Scope and Methodology ApendxiI

To do our work, we obtained Consolidated Health Centers program 

documents, pertinent studies, and data from the Department of Health and 

Human Services’ (HHS) Health Resources and Services Administration 

(HRSA). We also conducted structured interviews of officials from 12 

health centers in California, Illinois, Pennsylvania, and Texas. We selected 

these states because of their geographic diversity and because they were 

among the states with the highest number of health centers. Within each of 

the four states, we selected 3 health centers, including at least 1 urban and 

1 rural center in each state. To ensure that we could obtain information 

about securing specialty care for uninsured patients, we selected only 

centers where at least 26 percent of the patients were uninsured in 

calendar year 2003; 75 percent of all health centers had a proportion of 

uninsured patients of at least 26 percent. For each state we selected, we 

also interviewed officials from the state’s primary care association.1

 We 

also reviewed the relevant literature and program statutes and regulations 

and interviewed officials from the National Association of Community 

Health Centers and the National Association of Free Clinics.

To acquire information on health center funding, we examined 

Consolidated Health Centers program funding data by grant award type—

new access point, expanded medical capacity, service expansion, service 

area competition, and noncompeting continuation—for fiscal years 2002, 

2003, and 2004. In addition, we reviewed information on grant applications 

HRSA received during those 3 years. To describe the geographic 

distribution of health centers, we analyzed Uniform Data System (UDS) 

data on health center location by zip code and state and other data HRSA 

provided on centers’ urban/rural status. We assessed the reliability of the 

data on health center funding and geographic distribution of health centers 

by interviewing agency officials knowledgeable about the data and the 

systems that produced them, and we determined that the data were 

sufficiently reliable for the purposes of this report. 

To determine HRSA’s process for assessing the need for services, we 

reviewed agency grant announcements, grant applications, and application 

guidance documents for the various grant types. We also reviewed the 

need-for-assistance worksheet and the need criteria in the new access point 

grant application guidance. We interviewed agency officials about the 

criteria used to assess the application sections on need for services and 

1

Primary care associations are private, nonprofit membership organizations of health 

centers and other providers.
Appendix I

Scope and Methodology

Page 33 GAO-05-645 Health Centers

about HRSA’s ongoing consideration of revising the way need is assessed 

for new access point grants. In addition, we interviewed health center 

officials and officials from national and state associations that work with 

health centers about their experiences with the grant process. 

To examine HRSA’s monitoring of health center performance, we reviewed 

agency reports and protocols related to the new monitoring process 

conducted by the Office of Performance Review (OPR). We interviewed 

agency officials about the development of the new process and the roles 

played by different agency branches in monitoring health centers. To obtain 

information about health centers’ experiences with the new OPR 

performance review process, we conducted interviews with officials from 

health centers that had completed the process. One of the 12 original health 

centers we interviewed had completed the OPR performance review 

process, and we also interviewed officials at an additional 6 health centers 

that were among the first to complete the process. In addition, we reviewed 

documents provided by the health centers, including performance reports 

and action plans. We also reviewed reports and documents related to 

HRSA’s ongoing monitoring, including sample tools used by project officers 

to monitor their grantees and schedules of site visits conducted by the 

project officers. In addition, we reviewed documents related to HRSA’s 

collection of health center performance data, including agency guidelines 

for the Health Disparities Collaboratives and the application for health 

center participation in the Sentinel Centers Network. 

To assess HRSA’s improvements to UDS, we evaluated the completeness 

and quality of 2003 data—the most recent data available at the time we 

conducted our review. To evaluate overall completeness, we obtained the 

master list of 2003 grantees from HRSA and matched the grantees on this 

list with those in the 2003 UDS data file. To evaluate the completeness and 

quality of specific data elements in the 2003 UDS data file, we developed 

and evaluated edit checks of those data elements. We selected variables 

that were identified as problematic in our March 2000 report2

 and others 

that were used in our current analysis. We also independently conducted 

selected analyses and compared our findings to corresponding tables in the 

2003 National Rollup Report. For example, using 2003 UDS data, we 

duplicated the table on services offered and delivery method in the 

2

GAO, Community Health Centers: Adapting to Changing Health Care Environment Key 

to Continued Success, GAO/HEHS-00-39 (Washington, D.C.: Mar. 10, 2000). This report 

focused only on community and migrant health centers. 
Appendix I

Scope and Methodology

Page 34 GAO-05-645 Health Centers

National Rollup Report and verified that it matched the data HRSA 

reported. We did not perform edit checks on the delivery site data grantees 

reported to UDS. We interviewed agency officials about how HRSA 

collected UDS data on health center delivery sites and determined that the 

data were not sufficiently reliable for purposes of our report.

We conducted our work from August 2004 through June 2005 in accordance 

with generally accepted government auditing standards. 
Page 35 GAO-05-645 Health Centers

Appendix II

HRSA’s Process for Awarding Grants through 

the Consolidated Health Centers Program ApendxiI

HRSA’s process for awarding grants through the Consolidated Health 

Centers program involves several steps. HRSA provides initial grant 

information for new access point, expanded medical capacity, service 

expansion, and service area competition grants through the HRSA Preview, 

a notice available on HRSA’s Web site.1

 The preview includes information 

on eligibility requirements; the estimated number of awards to be made; the 

estimated amount of each award; and the dates that application guidance 

will be available, applications will be due, and awards will be made. HRSA 

later issues grant application guidance, which includes the forms 

applicants need to submit (such as forms describing the composition of the 

applicant’s governing board, summarizing the funding request, and 

describing the type of services to be provided) and a detailed description of 

the application review criteria and process. 

The application guidance for new access point grants also encourages 

applicants to submit a letter of interest prior to submitting a grant 

application. In the letter of interest, the applicant describes its community’s 

need for services and proposes services that the health center would offer 

to address those needs. HRSA officials told us that in fiscal year 2004, 

nearly one-half of applicants for new access point grants submitted a letter 

of interest. HRSA provides feedback to organizations on whether the 

proposal is consistent with the objectives of the health center program and 

whether HRSA thinks the organization is ready to establish a new delivery 

site. 

HRSA also provides applicants with technical assistance resources during 

the development of grant applications. For example, through cooperative 

agreements with HRSA, state primary care associations and the National 

Association of Community Health Centers offer regional training sessions 

on various topics, including strategic planning, proposal writing, 

community assessment, and data collection. Potential applicants may also 

contact their state primary care association for individual technical 

assistance and application review. 

1

The 2005 HRSA preview is available on HRSA’s Web site at 

http://www.hrsa.gov/grants/preview/.
Appendix II

HRSA’s Process for Awarding Grants through 

the Consolidated Health Centers Program

Page 36 GAO-05-645 Health Centers

HRSA approves funding for a specific project period—up to 5 years for 

existing grantees and up to 3 years for new grantees. HRSA provides funds 

for the first year of the project; for subsequent years, health centers must 

obtain funding annually through a noncompeting continuation grant 

application process in which the grantee must demonstrate that it has 

made satisfactory progress in providing services. A grantee’s continued 

receipt of funds also depends on the availability of funding.

Applications submitted to HRSA go through several stages of review. HRSA 

initially screens applications for eligibility based on specific criteria—the 

applicant must be a public or private nonprofit entity, the applicant must be 

applying for an appropriate grant (e.g., expanded medical capacity and 

service expansion grants are available only to existing grantees), and the 

application must include the correct documents and comply with page 

limitations and format requirements. 

Eligible applications go through a review process in which independent 

reviewers evaluate and score applications. The reviewers are selected by 

HRSA and have expertise in a specific field relevant to the health center 

program. HRSA provides reviewers with the same application guidance 

that it provides to applicants, and reviewers are to use their professional 

judgment in scoring applications. 

During the first stage of the review process, HRSA forwards eligible 

applications to three independent reviewers, who have 3 to 4 weeks to 

individually evaluate the applications. Applications for new access point 

grants include a need-for-assistance worksheet, which is evaluated by the 

reviewers. HRSA uses the need-for-assistance worksheet to measure 

barriers to obtaining care and to measure health disparity factors in the 

applicant’s proposed service area.2

 Applicants can score up to 100 points on 

the worksheet, and only those applicants that receive a score of 70 or 

higher on the worksheet go on to have the technical merits of their 

application evaluated. The reviewers evaluate the merits of all qualified

2

Measures of barriers to care include the distance or time to the nearest primary care 

provider and percentage of the population age 5 years or older who speak a language other 

than English. Health disparity factors include the rates of specific diseases and health 

outcomes, such as cancer, infant mortality, low-birth-weight infants, and teen pregnancy. 
Appendix II

HRSA’s Process for Awarding Grants through 

the Consolidated Health Centers Program

Page 37 GAO-05-645 Health Centers

applications; they base their review on a standard set of criteria (see table 

2) and give each application a preliminary score of up to 100 points. For 

example, reviewers of new access point grant applications evaluate the 

need for services through the criterion that describes the applicant’s 

service area/community and target population and assign a score from 0 to 

10, which constitutes a maximum of 10 percent of the applicant’s maximum 

final score. Similarly, reviewers evaluate the applicant’s service delivery 

strategy and model and assign a score from 0 to 20, which constitutes a 

maximum of 20 percent of the maximum final score. 
Appendix II

HRSA’s Process for Awarding Grants through 

the Consolidated Health Centers Program

Page 38 GAO-05-645 Health Centers

Table 2: Review Criteria for New Access Point, Expanded Medical Capacity, Service Expansion, and Service Area Competition 

Grants, Fiscal Year 2004

Source: HRSA’s fiscal year 2004 application guidance for new access point, expanded medical capacity, service expansion, and service 

area competition grants.

a

The readiness criterion refers to an applicant’s readiness to begin providing services.

b

The response criterion refers to an applicant’s description of its service delivery and business plans. 

c

The evaluative measures criterion refers to how the applicant plans to measure the success of its 

program.

d

The support requested criterion refers to an applicant’s proposed budget.

Grant Criteria 

Maximum

points

New Access Point Service delivery strategy and model 20

Health care services 15

Organizational capabilities and expertise 15

Budget 10

Description of the service area/community and target population 10

Governance 10

Readinessa 10

Strategic planning 10

Expanded Medical Capacity Need 25

Responseb 25

Evaluative measuresc 15

Resources/capabilities 15

Support requestedd 15

Impact 5

Service Expansion

(mental health/substance abuse and oral 

health services)

Responseb 60

Evaluative measuresc 10

Need 10

Resources/capabilities 10

Impact 5

Support requestedd 5

Service Area Competition Organizational capabilities and expertise 25

Service delivery strategy and model 20

Health care services 15

Budget 10

Description of the service area/community and target population 10

Governance 10

Strategic planning 10
Appendix II

HRSA’s Process for Awarding Grants through 

the Consolidated Health Centers Program

Page 39 GAO-05-645 Health Centers

During the second stage of the review process, reviewers present the 

strengths and weaknesses of the application to a panel of 10 to 15 

reviewers. After discussing the application, each panel member scores it. 

For each application, HRSA averages the scores assigned by each reviewer 

in the panel. The volume of applications may result in HRSA’s using 

multiple review panels during a funding cycle. When this occurs, HRSA 

uses a statistical method to adjust for variation in scores among different 

review panels. The adjusted score becomes the final application score, and 

the final scores are used to develop a rank order list of applicants.

HRSA bases its award decisions on the rank order of scores and other 

factors. Two types of factors—the funding preference and awarding 

factors—can affect which applicants HRSA chooses for funding from the 

rank order list. The funding preference is given to applicants proposing to 

serve a sparsely populated rural area.3

 To be considered for the preference, 

the applicant must demonstrate that the entire area proposed to be served 

by the delivery site has seven or fewer people per square mile. In addition 

to scoring an application, the review panel evaluates the requested funding 

amount and determines if an applicant should be considered for the 

funding preference. The funding preference does not affect the score, but 

may place an applicant in a more competitive position in relation to other 

applicants. For example, if the panel has determined that the applicant 

qualifies for the funding preference, it may receive a grant award over 

higher scoring applicants that did not qualify for the preference. In fiscal 

year 2004, of the five applicants that received a service expansion grant to 

provide new oral health services, three were determined to qualify for the 

funding preference. These three applicants—with scores of 83, 86, and 90—

were each awarded a grant over six applicants with application scores 

above 90. 

As with the funding preference factor, the law requires HRSA to consider 

awarding factors in selecting applicants to fund from the rank order list. 

HRSA must consider the urban/rural distribution of awards, the 

distribution of funds across types of health centers (community, homeless, 

migrant, and public housing), and a health center’s compliance with

3

42 U.S.C. § 254b(p). 
Appendix II

HRSA’s Process for Awarding Grants through 

the Consolidated Health Centers Program

Page 40 GAO-05-645 Health Centers

program requirements.4 In fiscal year 2004, HRSA gave priority to funding 

homeless and migrant health centers and, from the new access point 

applications the agency received that year, it funded only health centers 

requesting homeless or migrant health center funding.5

 HRSA officials said 

the agency did this because the applications it had already approved in 

fiscal year 2003 for funding in fiscal year 2004, pending funding availability, 

did not include applications for homeless or migrant health center funding. 

In addition to the preference and awarding factors specified in the law, 

HRSA also considers the geographic distribution of awards in making 

funding decisions.

HRSA sends a Notice of Grant Award to successful applicants. The notice 

includes a set of standard terms and conditions with which the grantee 

must comply to receive grant funds, such as allowable uses of federal funds 

and reporting requirements. In addition, the notice may include granteespecific conditions of award. For example, common conditions placed on 

new access point awards relate to the health center’s being operational 

within 120 days, having the appropriate governing board composition, and 

hiring key staff. About 80 percent of new access point awards receive at 

least one condition, according to HRSA officials. HRSA notifies 

unsuccessful applicants of the outcome of the review process and provides 

applicants with their score and a summary of their application’s strengths 

and weaknesses. 

4

The law requires new access point and service expansion grants to be awarded so that the 

population expected to be treated at centers receiving these grants is 40 to 60 percent rural. 

42 U.S.C. § 254b(k)(4). The law also requires awards to be made so as to maintain funding 

levels for the three types of centers serving special populations (homeless, migrant, and 

residents of public housing) at the same proportions that existed in fiscal year 2001.

42 U.S.C. § 254b(r)(2)(B). 

5

Of the applications received in fiscal year 2004, HRSA approved other types of health 

centers for funding in fiscal year 2005, pending funding availability. 
Page 41 GAO-05-645 Health Centers

Appendix III

Distribution of Consolidated Health Centers 

Program New Access Point Grants, Fiscal 

Years 2002 through 2004 ApendxiI

State/territory

Fiscal year

2002

Fiscal year

2003

Fiscal year

2004 Total

Alabama 1 0 2 3

Alaska 15 5 0 20

American Samoa 1 0 0 1

Arizona 2 4 1 7

Arkansas 3 1 0 4

California 29 19 9 57

Colorado 4 1 0 5

Connecticut 2 0 0 2

Delaware 1 0 0 1

District of Columbia 1 0 0 1

Federated States of Micronesia 0 0 0 0

Florida 4 2 1 7

Georgia 4 1 2 7

Guam 0 0 0 0

Hawaii 1 0 2 3

Idaho 2 0 1 3

Illinois 8 3 5 16

Indiana 1 2 3 6

Iowa 2 0 0 2

Kansas 0 1 0 1

Kentucky 2 1 0 3

Louisiana 1 1 3 5

Maine 0 0 3 3

Marshall Islands 0 0 0 0

Maryland 3 2 1 6

Massachusetts 5 1 2 8

Michigan 3 2 1 6

Minnesota 1 1 0 2

Mississippi 1 1 0 2

Missouri 4 0 2 6

Montana 2 3 0 5

Nebraska 0 2 0 2

Nevada 1 1 0 2

New Hampshire 2 0 1 3
Appendix III

Distribution of Consolidated Health Centers 

Program New Access Point Grants, Fiscal 

Years 2002 through 2004

Page 42 GAO-05-645 Health Centers

New Jersey 3 2 0 5

New Mexico 4 3 1 8

New York 9 6 2 17

North Carolina 2 4 1 7

North Dakota 1 3 0 4

Ohio 2 0 2 4

Oklahoma 3 1 1 5

Oregon 5 6 3 14

Palau 0 0 0 0

Pennsylvania 2 0 3 5

Puerto Rico 2 1 0 3

Rhode Island 0 2 2 4

South Carolina 7 2 0 9

South Dakota 3 1 0 4

Tennessee 2 3 0 5

Texas 5 2 5 12

Utah 1 2 0 3

Vermont 2 0 0 2

Virgin Islands 1 0 0 1

Virginia 4 3 2 9

Washington 2 1 2 5

West Virginia 3 3 0 6

Wisconsin 2 0 0 2

Wyoming 0 1 0 1

Total 171 100 63 334

(Continued From Previous Page)

State/territory

Fiscal year

2002

Fiscal year

2003

Fiscal year

2004 Total
Page 43 GAO-05-645 Health Centers

Appendix IV

Distribution of Consolidated Health Centers 

Program Grantees, 2001 and 2003 ApendxiIV

State/territory 2001 2003

Alabama 15 15

Alaska 6 21

American Samoa 0 1

Arizona 13 14

Arkansas 9 10

California 57 83

Colorado 14 15

Connecticut 9 10

Delaware 3 3

District of Columbia 1 2

Federated States of Micronesia 1 1

Florida 30 32

Georgia 20 22

Guam 1 1

Hawaii 8 10

Idaho 6 7

Illinois 25 31

Indiana 8 11

Iowa 7 8

Kansas 7 8

Kentucky 11 12

Louisiana 15 16

Maine 12 12

Marshall Islands 1 1

Maryland 11 13

Massachusetts 28 33

Michigan 24 26

Minnesota 10 12

Mississippi 21 21

Missouri 14 17

Montana 7 11

Nebraska 3 5

Nevada 2 2

New Hampshire 5 7

New Jersey 13 16
Appendix IV

Distribution of Consolidated Health Centers 

Program Grantees, 2001 and 2003

Page 44 GAO-05-645 Health Centers

Source: HRSA’s UDS, Calendar Year 2001 Data: National Rollup Report, Rollup Summary and Calendar Year 2003 Data: National 

Rollup Report, Rollup Summary.

Note: Table includes the 748 and 890 grantees that submitted data to the 2001 and 2003 UDS, 

respectively. The 2001 data provide the number of grantees operating before the President’s Health 

Centers Initiative began and the 2003 data were the most recent data available at the time we 

conducted our review.

New Mexico 12 14

New York 44 51

North Carolina 21 25

North Dakota 1 5

Ohio 19 21

Oklahoma 4 6

Oregon 11 16

Palau 1 1

Pennsylvania 27 29

Puerto Rico 20 20

Rhode Island 5 6

South Carolina 19 21

South Dakota 6 7

Tennessee 19 23

Texas 31 35

Utah 9 11

Vermont 2 3

Virgin Islands 2 2

Virginia 18 18

Washington 21 22

West Virginia 22 27

Wisconsin 13 14

Wyoming 4 4

Total 748 890

(Continued From Previous Page)

State/territory 2001 2003
Page 45 GAO-05-645 Health Centers

Appendix V

Comments from the Health Resources and 

Services Administration ApendxiV
Appendix V

Comments from the Health Resources and 

Services Administration

Page 46 GAO-05-645 Health Centers
Page 47 GAO-05-645 Health Centers

Appendix VI

GAO Contact and Staff Acknowledgments ApendxiVI

GAO Contact Helene F. Toiv, (202) 512-7162

Acknowledgments In addition to the person named above, key contributors to this report were 

Donna Almario, Janina Austin, Anne McDermott, Julie Thomas, Roseanne 

Price, and Daniel Ries.

(290400)
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Washington, D.C. 20548