[Federal Register Volume 70, Number 23 (Friday, February 4, 2005)]
[Notices]
[Pages 6016-6023]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 05-2215]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration


Development 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

AGENCY: Health Resources and Services Administration, HHS.

[[Page 6017]]


ACTION: Solicitation of comments.

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SUMMARY: Currently, application scores for New Access Point (NAP) 
applications under the President's Health Centers Initiative (Program) 
cluster at the high end of the scoring range, providing little 
distinction among applicants. Since the intent of the Program is to 
provide grants to the neediest communities, HRSA is considering placing 
more emphasis on assessing the need for comprehensive primary and 
preventive health care services in the service area or for the 
population for which the applicant is seeking support, by revising the 
Need for Assistance Criteria and changing the relative weights of the 
review criteria used in evaluating such applications. This notice 
offers public and private nonprofit entities an opportunity to comment 
on the proposed changes in the Need for Assistance Criteria (NFA), and 
on the degree to which need should be weighted relative to other 
criteria used in evaluating future applications. In order to solicit 
comments from the public on these proposed changes, HRSA is delaying 
the due date (May 23, 2005) for the second round of fiscal year (FY) 
2005 New Access Point applications.
    Authorizing Legislation: Section 330(e)(1)(A) of the Public Health 
Service Act, as amended, authorizes support for the operation of public 
and nonprofit private health centers that provide health services to 
medically underserved populations.
    Reference: For the current Need for Assistance (NFA) criteria and 
other application review criteria, including weights used most 
recently, see Program Information Notice (PIN) 2005-01, titled 
ARequirements of Fiscal Year 2005 Funding Opportunity for Health Center 
New Access Point Grant Applications,'' are available on HRSA's Bureau 
of Primary Health Care (BPHC) Web site at http://bphc.hrsa.gov/pinspals/pins.htm. That PIN detailed the eligibility requirements, 
review criteria, and awarding factors for applicants seeking support 
for the operation of New Access Points in FY 2005.
    Background: The goal of the President's Health Centers Initiative, 
which began in FY 2002, is to increase access to comprehensive primary 
and preventive health care services to 1,200 of the Nation's neediest 
communities through new and/or significantly expanded health center 
access points over five years. These health center access points are to 
provide comprehensive primary and preventive health care services in 
areas of high need that will improve the health status of the medically 
underserved populations to be served and decrease health disparities. 
Services at these new access points may be targeted toward an entire 
community or service area or toward a specific population group in the 
service area that has been identified as having unique and significant 
barriers to affordable and accessible health care services.
    While it is extremely important that NAP grant awards be made to 
entities that will successfully implement a viable and compliant 
program for the delivery of comprehensive primary health services to 
the populations or communities they propose to serve, HRSA also needs 
to assure that all applicants seeking support for a NAP applicant can 
demonstrate the need for such services in the community (area or 
population group) to be served and be evaluated on that need. Under the 
current guidance, NFA criteria are used to quantify barriers to access 
and identify health disparities. The NFA process also establishes a 
threshold which applicants must meet in order for their applications to 
be reviewed by the Objective Review Committee (ORC).
    Description of Current NFA process. The current NFA process (as 
described in Form 9-Part A of PIN 2005-01) involves two major groups of 
indicators. First, from eight (8) ``Barriers and Access to Care'' 
measures, the applicant must select five (5). These measures are: 
Shortage of primary care physicians, as measured by whether the target 
service area has been designated as a geographic or population group 
Health Professions Shortage Area (HPSA); Percent of the population with 
incomes below 200% of the Federal poverty level; Life expectancy of 
target population (in years); percentage of target population 
uninsured; unemployment rate of target population; average travel time 
or distance to nearest source of primary care for target population; 
percentage of target population age 5 or older who speak a language 
other than English at home; and length of waiting time for public 
housing and Section 8 certificates for target population. For the first 
of these measures, the applicant receives 14 points if HPSA-designated 
and zero otherwise; for each of the other measures, the NFA criteria 
define a 6-level scale from 0 to 14 points. The applicant provides data 
for its service area or target population for each of the 5 measures 
selected, and identifies the source of data used. Given 5 indicators 
and a maximum of 14 points for each, there are a possible 70 points for 
the ``Barriers and Access to Care'' indicators.
    Second, from 28 ``Health Disparity Factors'', the applicant selects 
10 and provides data on each for its service areas or target 
populations. For each factor selected, the applicant can receive 3 
points if the value for the target population exceeds the benchmark 
used. The applicant defines the benchmark, and gives a source for that 
benchmark as well as a source for the target population data provided. 
The guidance lists 27 specific factors, plus an ``other'' category 
allowing the applicant to select one additional locally-relevant factor 
not anticipated by the guidance. This approach produces a possible 30 
points for the ``Health Disparities Factors'' section; combined with 
the possible 70 for ``Barriers and Access to Care'' section, allowing a 
possible 100 total points are possible. In current guidance, the 
threshold for having the application reviewed has been set at an NFA 
score of 70 out of the possible 100 total points.

Need for Assistance Worksheets and the Application Review Process

    In accordance with the guidance, all applicants are required to 
complete an NFA Worksheet, identifying the NFA indicators they have 
selected from the options available and providing the data on these 
indicators for their proposed service area or target population. The 
Worksheet is reviewed by an Objective Review Committee (ORC), and only 
those applicants that achieve a score of 70 or higher out of the 
possible 100 points have the merits of their application evaluated by 
the ORC. To date, under the President's Initiative, HRSA has found that 
most applicants achieve the minimum of 70 NFA points required in the 
current process for consideration of their application. Furthermore, 
under the current application review process, only 10% of the total 
(100) possible points are allocated to the applicant's description of 
the need for additional primary care services in the community or 
target population to be served. Currently, application scores cluster 
at the high end of the scoring range, providing little discrimination 
among applications.
    For these reasons, HRSA arranged for an external evaluation of the 
NFA criteria and the use of need factors in the overall application 
review process. (The evaluation was conducted by a team of HSR, Inc., 
and the University of North Carolina's Cecil G. Sheps Center for Health 
Services Research.) Key results of the evaluation analyses are 
presented below, followed by recommendations for proposed changes on 
which we are soliciting comments.

[[Page 6018]]

Current NFA Access Barriers--Frequency of Applicant Use; Scores 
Achieved

    An analysis of applications received during FY 2004 indicated that, 
with respect to the eight ``Barriers and Access to Care'' indicators, 
92% of applicants selected the indicator percent of target population 
below 200% poverty; 79% selected percent of target population 
uninsured; 78% selected shortage of primary care physicians; and 75% 
selected unemployment rate for the target population, while only 36% 
selected life expectancy of the target population and 34% selected 
travel time or distance. Language other than English and shortage of 
Public Housing were selected by 55% and 50% of the applicants 
respectively. Since applicants naturally chose the variables that gave 
them the highest scores, the average scores achieved on all of the 
``Barriers and Access to Care'' indicators ranged from 12 to 14 for 
each, except for life expectancy, which had an average score of about 
11. As a result, scores of 60 or more for the ``Barriers and Access to 
Care'' section were routinely obtained.
    Current NFA Disparity Factors--Frequency of use by applicants. A 
similar analysis of the ``Health Disparity Factors'' selected by the 
same group of applicants showed that 8 indicators were selected by 50% 
or more of the applicants, and another 7 indicators were selected by 
one-third or more applicants. Twelve indicators were selected by 25% or 
fewer of the applicants. Ninety-five percent of the time a selected 
indicator received 3 points; only 5% of the time did an applicant 
receive 0 rather than 3 points for a disparity indicator supplied. 
Therefore, typically, at least 27 points were received for the ``Health 
Disparities Factors'' section. Combining at least 60 points for the 
``Barriers and Access to Care'' section access barriers and 27 points 
for the ``Health Disparities Factors'' section, a typical application 
would get 87 points, easily exceeding the threshold of 70.
    Distribution of All U.S. Counties on Current NFA Barrier Score 
Levels. To arrive at an understanding of why the scores for access 
barriers ran so high for most applications, an analysis of the scores 
that would be achieved by all 3,141 U.S. counties or county-equivalents 
was conducted. This analysis showed that, given the existing scales:
    <bullet> On Percent Below 200% of Poverty, 665 of 3141 counties 
receive 14 points, another 993 receive 12 points, and 946 receive 10 
points. The average county score is 11 points.
    <bullet> On Life Expectancy, only 17 counties receive 14 points, 
but 601 counties receive 12 points, and 2,140 receive 10 points. The 
average county score is 10.1 points.
    <bullet> On Unemployment Rate, the counties are distributed more 
evenly along the scoring scale, but only 2 counties receive zero 
points, and the average county score is 9.5 points.
    <bullet> On Percent Uninsured, 1,609 counties receive 10 points, 
while 1,327 receive 8 points. The average county score is 9 points.
    <bullet> By contrast, Travel Time/Distance shows better 
distinctions among counties using its existing scale; while 1,527 
counties receive zero points, 950 receive 6 points, 294 receive 8 
points, 112 receive 10 points, 52 receive 12 points and 51 receive 14 
points. The average score is 3.5. HRSA is requesting feedback as to 
whether the scale should be adjusted to increase the numbers of 
counties getting 10, 12 or 14 points?
    <bullet> In the case of Language other than English, the current 
scale seems to err in the direction of overly minimizing the points 
received: 2,410 counties receive zero points, and the average county 
score is only 1.8 points.
    <bullet> On Shortage of Primary Care Physicians, 2,565 counties 
receive no points while 576 receive 14 points. This means that about 
one-sixth of counties are getting the maximum points, because they are 
wholly designated as HPSAs. This does not provide any flexibility in 
terms of the rest of the counties, some of which may be closer to 
eligibility for HPSA designation than others, while others contain 
part-county HPSAs.
    Recommendations for Revising NFA Criteria/Worksheet. Based on the 
analysis described above, feedback from communities, applicants and 
several focus group sessions, HRSA is proposing the following changes 
to the NFA criteria and process:
    <bullet> Require that three (3) major access barriers be measured 
for all applicants. These three would be (a) percent of the population 
with incomes below 200 percent of the poverty level, (b) percent of 
population uninsured, and (c) shortage of primary care physicians, the 
three barriers that are most frequently selected by applicants.
    <bullet> Use the population-to-primary care physician ratio for the 
applicant's service area or target population as the measure of 
shortage of primary care physicians, rather than a simple yes/no 
response based on presence or absence of a HPSA designation, with a 
scale of the type used for the other access indicators.
    <bullet> Allow the applicant to select two additional access 
barriers from the following five (5): Unemployment Rate of Population, 
Percent Linguistically Isolated Population (replacing language other 
than English), Standardized Mortality Rate for Population (replacing 
Life Expectancy Rate), Travel Time/Distance to Nearest Provider 
accepting Medicaid and/or Uninsured Patients, and (for Homeless or 
Public Housing applicants only) Waiting time for Public Housing.
    <bullet> Choose the scale for each of the access indicators based 
on comparison to the national county distribution of that indicator. 
(The scales proposed to be used are displayed below.) No points would 
be awarded for a barrier value better than the national county median.
    <bullet> Require that 5 ``core'' disparity factors closely related 
to health center primary care activities be measured for all 
applicants. The core indicators proposed are: asthma rate, diabetes 
rate, and cardiovascular disease rate among the population; one birth 
outcome measure (infant mortality rate or low live birthweight rate), 
and one mental health measure (depression rate or suicide rate) among 
population. [Of these factors, all but one (depression rate) were in 
the group of current indicators selected at least 33% of the time.]
    <bullet> Allow 2 points for each core disparity factor on which the 
community value exceeds the national benchmark for that factor, which 
would be provided in HRSA's application guidance (rather than by the 
applicant). Allow an additional point if a higher ``severe'' benchmark, 
also specified in the guidance, is also exceeded. (Benchmarks proposed 
are appended below.)
    <bullet> Have the applicant select 5 additional disparity factors 
from a list of 7 factors previously used that are closely related to 
health center primary care activities. The factors proposed are: 
immunization rate, hypertension rate, rate of respiratory infection, 
obesity, teenage pregnancy, substance abuse, and percent elderly 
population. Alternatively, the applicant may select 4 of these plus an 
``other'' indicator specified by the applicant.
    <bullet> Allow 2 points for each selected measure on which the 
community value exceeds the national benchmark. (Benchmarks proposed 
are appended below.) If ``other'' is selected, the applicant would need 
to both define the measure and suggest a benchmark for it as well. If 
the measure and the benchmark are accepted (or if the

[[Page 6019]]

measure is accepted but the benchmark is redefined), 2 points would be 
allowed if the benchmark is exceeded.
    <bullet> Maximum possible total points for access barriers here is 
75; and for disparities is 25 points, totaling 100 possible total 
points for NFA.
    <bullet> A threshold of 50 points on this revised index is under 
consideration. Only those applicants with a NFA score of 50 or more 
would have their application reviewed by the ORC. HRSA is considering 
whether this threshold should be changed annually to maintain a certain 
ratio of number of applications reviewed to number of awards available.
    <bullet> The NFA scores achieved could be factored into the 
application review process.

Relative Importance of Need as an Application Review Factor

    The evaluation team also recommended that the relative need score 
from the NFA worksheet should be the basis for 20 percent of total 
application score, replacing the previous 10% for ``description of 
service area/community and target population.'' To accommodate this 
change, the evaluation team suggested reducing the proportion of the 
total application score now assigned to ``Governance'' from 10% to 5%, 
and reducing the proportion of total score assigned to ``Service 
Delivery Strategy and Model'' from 20% to 15%. However, HRSA has not 
taken a position on what new relative weighting might be most 
appropriate. Instead, by this notice, we are requesting public comments 
on this issue. Specifically, how should Need considerations be weighted 
in the application review process? What is the relative importance of 
Need versus such other factors as applicant Readiness to operate a 
health center, understanding of and connections to the local health 
care Environment, service delivery Strategy for addressing the needs of 
the community, plan for provision of specific required health Services, 
Organizational capabilities and expertise, Budget plan, and Governance? 
Rather than providing specific suggested percentages for weighting all 
these different factors, commenters are encouraged to isolate how Need 
should be weighted relative to all other factors, and whether this 
should be done by applying that weight to an objective index of 
relative community need such as that proposed above, or in some other 
manner.
BILLING CODE 4165-15-P

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DATES: Please send comments no later than COB March 7, 2005. The 
comments should be addressed to Dr. Sam Shekar, Associate Administrator 
for Primary Health Care, Health Resources and Services Administration, 
Room 17-99,

[[Page 6023]]

5600 Fishers Lane, Rockville, Maryland 20857.

FOR FURTHER INFORMATION CONTACT: Ms. Lynn Spector, Division of Health 
Center Development, Bureau of Primary Health Care, HRSA. Ms. Spector 
may be contacted by e-mail at <a href="/cdn-cgi/l/email-protection#462a35362325322934062e34352768212930"><span class="__cf_email__" data-cfemail="0f637c7f6a6c7b607d4f677d7c6e21686079">[email protected]</span></a> or via telephone at 
(301) 594-4300.

    Dated: February 1, 2005.
Elizabeth M. Duke,
Administrator.
[FR Doc. 05-2215 Filed 2-1-05; 4:24 pm]
BILLING CODE 4165-15-C


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