Health Centers: Competition for Grants and Efforts to Measure Performance Have Increased
Published: 2005-07-13T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: 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.
section_title: What GAO Found
paragraphs: 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.

section_title: Letter
paragraphs: 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,  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 care—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 for expanded services at existing sites— and increase the number of  people served annually to about 16 million by the end of fiscal year 2006.
Federal community and migrant health centers were established in the mid- 1960s, 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. 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.
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  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.)
subsections: section_title: Background
paragraphs: 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.
Health centers are required by law to serve a federally designated medically  underserved area or a federally designated medically underserved  population. 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  ethnic minority populations, and 30 percent spoke a primary language  other than English.
subsections: section_title: Health Center Organization and Services
paragraphs: 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.
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  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. Services must be provided regardless of  patients’ ability to pay. 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.
section_title: HRSA’s Award Process for Grants Funded through the Consolidated Health Centers Program
paragraphs: 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. 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). 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,  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.
section_title: HRSA’s Monitoring of the Consolidated Health Centers Program
paragraphs: 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, 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  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. 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, 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  (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. 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.
section_title: Competition for Health Center Funding Has Increased, and HRSA Is Evaluating Its Process for Assessing Need
paragraphs: 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.
subsections: section_title: Funding for Grants to Increase Health Center Services Has Become More Competitive Since the President’s Health Centers Initiative Began
paragraphs: 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.
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. (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.
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 and 57 percent of fiscal year 2002 service expansion applicants; 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. 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.
section_title: HRSA’s Process for Assessing Need for New Access Point Grants Has Changed
paragraphs: 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 worksheet 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-for- assistance worksheet score, HRSA also increased the relative weight of the  need criterion in the application score. In fiscal year 2002, the maximum  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-for- assistance 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-for- assistance 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.
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-for- assistance worksheet and to substitute the need-for-assistance worksheet  for the current need criterion in the grant application. 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,  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.
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. 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 high- poverty counties and planning grants to community-based organizations to  support the establishment of centers in such counties.
section_title: Number of New Access Point Grantees Varies Widely by State, but HRSA Lacks Reliable Information on Delivery Sites
paragraphs: 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. During that period, HRSA awarded 334 new access point  grants, with at least one grantee in each state. 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.)
In 2003, the distribution of all health center grantees was 48 percent urban  and 52 percent rural. HRSA is required by law to make awards so that 40  to 60 percent of patients expected to be served reside in rural areas.  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  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.
section_title: HRSA Has Increased the Role of Performance Measurement in Monitoring and Improved Its Collection of Health Center Data
paragraphs: 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.
subsections: section_title: HRSA’s New Process for Monitoring Health Centers and Other Data Collection Tools Include Patient Health Outcome Measures
paragraphs: 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. 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. For  the health centers we contacted that had undergone the OPR performance  review, 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  born to health center patients. 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. 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 low- birth-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.
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. 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  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. The network is intended to  supplement HRSA’s other data sources, such as the Community Health  Center User and Visit Survey,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 collaborative. 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. 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. 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.
section_title: HRSA Has Taken Actions to Improve the Completeness and Accuracy of Its Uniform Data System
paragraphs: Since our previous report on the health centers program in March 2000,  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.
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. 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 there is an error in the data or if there is a reasonable explanation. 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.  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. 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.
section_title: Health Centers Often Face Challenges Securing Specialty Care for Patients
paragraphs: 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. 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, 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, 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.
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.
section_title: Conclusions
paragraphs: 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  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.
section_title: Recommendation for Executive Action
paragraphs: 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.
section_title: Agency Comments
paragraphs: 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  provided technical comments, and we revised our report to reflect the  comments where appropriate.
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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.
section_title: Scope and Methodology
paragraphs: 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. 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  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 report 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  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.
section_title: HRSA’s Process for Awarding Grants through the Consolidated Health Centers Program
paragraphs: 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. 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.
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. 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 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.
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. 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 program requirements. 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. 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 grantee- specific 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.
section_title: Distribution of Consolidated Health Centers Program New Access Point Grants, Fiscal Years 2002 through 2004
paragraphs: 3 (Continued From Previous Page)
section_title: Distribution of Consolidated Health Centers Program Grantees, 2001 and 2003
paragraphs: 16 (Continued From Previous Page)
section_title: Comments from the Health Resources and Services Administration
section_title: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Acknowledgments
paragraphs: 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.