Health Careers Opportunity Program: Process for Awarding Competitive Grants Included Independent Review
Published: 2007-02-02T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: To support the education and training of health professionals, the Health Resources and Services Administration (HRSA), in the Department of Health and Human Services (HHS), administers health professions education programs authorized under title VII of the Public Health Service Act. One of these programs, the Health Careers Opportunity Program (HCOP), provides grants to health professions schools and other entities to help students from disadvantaged backgrounds prepare for health professions education and training. Funding preference is given to grant applications that demonstrate a comprehensive approach involving other educational or health-related partners. Congressional committees have encouraged HRSA to give priority to applications from schools with a historic mission of educating minority students for health professions. In 2004, the appropriations conference committee asked GAO to review HRSA's process for awarding grants. This report addresses, for fiscal years 2002 through 2005, (1) HRSA's process for awarding HCOP grants and (2) the number and characteristics of HCOP applicants and grantees. GAO reviewed data from HRSA, interviewed HRSA officials, and reviewed relevant federal laws and agency documents from HHS and the Department of Education.
section_title: What GAO Found
paragraphs: HRSA followed a standard process to award HCOP grants, distributing funds on a noncompetitive basis to continue funding existing HCOP grants within their approved project periods, and then awarding the remaining funds on a competitive basis. For each of fiscal years 2002-05, HRSA competitively awarded between $4 million and $15 million from the approximately $34 million annually available for HCOP. To award competitive grants, HRSA used independent reviewers who assessed applications against published criteria, scored applications that met minimum criteria, and determined if they qualified for the funding preference. HRSA ranked the applications from highest to lowest score--putting those with the funding preference first--and awarded grants in decreasing rank order until the available funds were exhausted. Although HRSA had discretion to award grants out of rank order, the agency did not do so for fiscal years 2002-05. For fiscal years 2002-05, HRSA awarded a total of 99 competitive HCOP grants from 439 grant applications reviewed. Overall, minority-serving institutions submitted about 25 percent of the applications reviewed and received about 30 percent of the competitive grants; historically black colleges and universities were the most numerous grantees among minority-serving institutions, followed by Hispanic-serving institutions. HRSA commented that a draft of this report met the goals of describing the award process and outlining the number and characteristics of HCOP applicants and grantees.

section_title: Letter
paragraphs: An appropriate supply of health professionals is vital to ensuring that all  Americans have adequate access to health care. To support the education  and training of health professionals, the Health Resources and Services  Administration (HRSA), an agency within the Department of Health and  Human Services (HHS), administers numerous health professions  education and training programs authorized under title VII of the Public  Health Service Act. One such program, the Health Careers Opportunity  Program (HCOP), provides grants to health professions schools—such as  medical or dental schools—and other entities to help students from  disadvantaged backgrounds prepare for, and succeed in, education and  training for the health professions. HCOP grants are generally approved  for a period of 3 years and support activities such as training to help  students prepare for health professions education as well as counseling  and mentoring for those already enrolled. Preference in funding HCOP  grants is given to applications for projects with a comprehensive  approach, including partnerships among health or educational entities to  develop a pool of individuals from disadvantaged backgrounds interested  in pursuing health careers. Applications that receive this funding  preference are considered for funding ahead of applications that do not.
For each of fiscal years 2002 through 2005, HRSA awarded about   $34 million for HCOP grants, including grants awarded on a competitive  basis as well as funds distributed on a noncompetitive basis to continue  funding existing HCOP grant projects within their approved project  periods. For fiscal year 2006, in response to direction received during the  appropriations process, funding made available for HCOP by HRSA from  its appropriations was reduced significantly. As a result, HRSA cancelled  the competition for grants and distributed all funds available for HCOP for  fiscal year 2006—about $4 million—on a noncompetitive basis to continue  funding 4 of 58 existing HCOP grant projects within their approved project  periods. In response to guidance in an appropriations committee report,  which strongly urged HRSA to give priority to those institutions with a  historic mission of training minorities in the health professions, the  agency distributed the $4 million for fiscal year 2006 to continue funding  existing HCOP grant projects at four institutions that met that criterion.
All projects supported by HCOP grants focus on individuals who are either  educationally or economically disadvantaged. In reports accompanying  HHS appropriations bills for fiscal years 2002 through 2004, congressional  appropriations committees with responsibility for HHS programs noted  with approval that HRSA had given “priority consideration for HCOP  grants to minority health professions institutions.” In the conference  report accompanying the fiscal year 2005 appropriations act, however, the  conference committee expressed concern that several applications for  new or competitive continuation grants from historically minority health  professions schools had not been funded for fiscal year 2004. In this  report, the conference committee also directed us to study the HCOP grant  award process. As discussed with the appropriations subcommittees with  responsibility for HHS programs, this report addresses, for fiscal years  2002 through 2005, (1) HRSA’s process for awarding HCOP grants and   (2) the number and characteristics of HCOP applicants and grantees.
To conduct our work, we analyzed HRSA’s data on HCOP applications,  including the scores and funding preference determinations made during  the application review process, and HCOP grant award decisions for fiscal  years 2002 through 2005. We assessed the reliability of HRSA’s data on  HCOP grant awards by discussing with agency officials the validation and  internal controls applied to HRSA’s grant data and by comparing the data  with HRSA documents, such as records of HCOP grant award decisions.  We determined that the HCOP data were sufficiently reliable for our  purposes. In addition, we interviewed HRSA officials and reviewed  relevant federal laws, congressional committee reports, and agency  documents. In reviewing the characteristics of entities submitting HCOP  applications and of HCOP grantees, we included only those applications  that HRSA officials determined met the initial screening requirements to  be considered for awards. To determine whether applicants and grantees  that were institutions of higher education met criteria for designation as  minority-serving institutions, we used Department of Education  documents and other sources. We conducted our work from October 2005  through January 2007 in accordance with generally accepted government  auditing standards.
subsections: section_title: Background
paragraphs: First authorized in 1971, the program currently known as HCOP was last  reauthorized in 1998. The Secretary of Health and Human Services is  authorized to make HCOP grants “for the purpose of assisting individuals  from disadvantaged backgrounds . . . to undertake education to enter a  health profession.” A wide range of entities are eligible to receive HCOP  grants, including, for example, schools of medicine, dentistry, and  pharmacy; schools with graduate programs in behavioral and mental  health; programs to train physician assistants; and other public or private  nonprofit health or educational entities. HCOP grant funds may be used  for a variety of activities, such as recruiting individuals from  disadvantaged backgrounds interested in health careers; facilitating their  entry into health professions schools; providing counseling, mentoring,  and other support activities designed to assist them to complete this  education; providing information on financial aid; and providing  experience in primary health care settings.
The 1998 reauthorization of HCOP emphasized the importance of outreach  activities by adding a funding preference for HCOP applications for  projects that “involve a comprehensive approach by several public or  private nonprofit health or educational entities to establish, enhance and  expand educational programs that will result in the development of a  competitive applicant pool of individuals from disadvantaged backgrounds  who desire to pursue health professions careers.” Applications qualifying  for this funding preference have an advantage because they must be  considered for funding ahead of applications that do not.
Projects supported by HCOP grants focus on individuals from  disadvantaged backgrounds, and Congress has recognized that such  individuals may be members of minority groups. The Public Health Service  Act directs the Secretary of Health and Human Services “to the extent  practicable,  ensure that services and activities  are  adequately allocated among the various racial and ethnic populations who  are from disadvantaged backgrounds.” Section 739 of the Public Health  Service Act does not specify any particular populations or methods that  HRSA must use to ensure this allocation, leaving these decisions to the  agency’s discretion. According to HRSA officials, in the 1990s, the agency  allocated additional points to the scores of applications from historically  black colleges and universities, Hispanic-serving institutions, and tribal  colleges and universities to improve their chances of receiving an HCOP  grant. HRSA reported that for 1997 this practice resulted in its awarding  eight more HCOP grants to historically black colleges and universities than  it had awarded for the previous year.
section_title: HRSA Followed a Standard Process to Award HCOP Grants
paragraphs: For fiscal years 2002 through 2005, HRSA followed a standard process to  award HCOP grant funds, distributing the program’s available funds on a  noncompetitive basis to continue funding existing grant projects, then  awarding the remaining funds on a competitive basis. For competitive  HCOP grants, HRSA published criteria and relied on the assessment of  independent reviewers. Grants were awarded in accordance with the  applications’ rank order as determined by the independent reviewers.
subsections: section_title: HRSA Funded Existing HCOP Projects Before Awarding Competitive Grants
paragraphs: The amount of HCOP funds HRSA distributed each year on a  noncompetitive basis to continue funding existing grant projects  determined the amount that remained available for competitive grants and,  consequently, the number of competitive grants HRSA awarded. For fiscal  years 2002 through 2005, the amounts HRSA made available for HCOP  grants from its annual appropriations remained relatively stable, with an  average of about $34 million a year over the 4 fiscal years. Before making  competitive awards, HRSA distributed funds each year on a  noncompetitive basis to support existing HCOP grant projects in their  second or subsequent years. These noncompetitive continuation awards  were subject to HRSA officials’ approval after the agency reviewed each  grantee’s annual progress report. Once the noncompetitive continuation  awards were made, HRSA awarded the remaining HCOP funds on a  competitive basis, including new grants to entities that did not have an  HCOP grant for a particular project and competitive continuation grants to  entities that applied for continued funding after the end of their authorized  HCOP grant period. As shown in figure 1, the amounts distributed on a  noncompetitive basis to continue funding existing grant projects varied,  from a low of $18 million for fiscal year 2005 to a high of $30 million for  fiscal year 2003, and the remaining funds awarded as competitive grants  ranged from a low of $4 million for fiscal year 2003 to a high of $15 million  for fiscal year 2005.
section_title: HRSA’s Process for Awarding Competitive Grants Was Based on Published Criteria
paragraphs: For each of fiscal years 2002 through 2005, HRSA published a notification  of upcoming grant opportunities, including those for HCOP grants. This  notification provided an overview of the HCOP program, including the  entities eligible to receive HCOP grants and a description of the funding  preference for projects with a comprehensive approach. For detailed  review criteria, the annual notification referred prospective HCOP  applicants to the HCOP program guidance available on request or, for  fiscal year 2005, through HRSA’s Web site.
The review criteria HRSA published in its HCOP program guidance  addressed different aspects of a successful HCOP project. Each criterion  carried a specified number of potential points, for a maximum total score  of 100. For some criteria, the point values differed according to whether  the application was for a new grant or a competitive continuation grant.  This difference reflected the fact that applications for competitive  continuation grants were required to include a summary of the grantee’s  management of its previous HCOP grant project and of progress toward  meeting its objectives. For all applications for competitive grants—both  new and competitive continuations—HRSA assigned the greatest number  of potential points to the criterion that addressed plans to implement the  HCOP activities authorized in the Public Health Service Act. Table 1  summarizes the criteria used by reviewers to assess HCOP applications for  fiscal year 2005.
The HCOP program guidance also included information on how to apply  for, and receive, the funding preference for projects involving a  comprehensive approach. To receive the funding preference, applicants  were required to meet all four of the following statutory requirements:    Demonstrate a commitment to a comprehensive approach through formal  signed agreements that specify common objectives and establish  partnerships with institutions of higher education, school districts, and  other community-based entities.
Enter into formal signed agreements reflecting the coordination of  educational activities and support services and the consolidation of  resources within a specific area.
Design activities that establish a competitive health professions applicant  pool of individuals from disadvantaged backgrounds by focusing on both  academic and social preparation for health careers.
Describe educational activities that focus on developing a culturally  competent health care workforce to serve needy populations in the  geographic area.
HRSA’s HCOP program guidance for fiscal years 2002 through 2005  specified that, to receive the funding preference, copies of formal  agreements between applicants and community-based partners must be  included with the application.
section_title: HRSA’s Process for Awarding Competitive Grants Relied on Assessment by Independent Reviewers
paragraphs: For fiscal years 2002 through 2005, HRSA’s standard process for awarding  competitive HCOP grants relied on independent reviewers to assess  applications against the agency’s published review criteria. HRSA officials  generally limited their own review of applications for competitive HCOP  grants to screening for applicant eligibility and compliance with technical  requirements such as format and length.
After determining which applications met basic eligibility requirements,  HRSA officials forwarded all eligible HCOP applications to the agency’s  Division of Independent Review to arrange for assessment and scoring.  To assess HCOP applications, the division selected reviewers with health- related educational, counseling, academic, or project management  experience who were not employed by HRSA and who were free from  conflicts of interest, including employment or consulting arrangements  with any entity that was applying for an HCOP grant for that fiscal year.  The division sent each reviewer about eight applications to read in  advance, then convened multiple panels in which reviewers met to discuss  the merits of those applications. The reviewers were instructed to apply  the published HCOP review criteria and reach consensus within each  panel on their funding recommendations. The reviewers did not  recommend for approval those applications they determined were not  responsive to the review criteria. For each application recommended for  approval, the reviewers assigned a score and determined whether the  application qualified for the funding preference. The reviewers also had  the opportunity to comment on applications’ proposed budgets and to  recommend adjustments for reasonableness.
After the independent reviewers completed their assessments, HRSA  officials used a statistical method to standardize the results from all HCOP  review panels for a given year into a single ranked list, placing all  applications receiving the funding preference ahead as a group, from  highest to lowest score, followed by applications without the funding  preference, from highest to lowest score. HRSA officials used this rank- order list as their basis for recommending which applications should  receive grants for a given fiscal year and the amount of each award. The  HRSA officials’ recommendations were included in memorandums to the  HRSA Administrator, who made the final award decisions for fiscal years  2002 through 2005. Figure 2 provides an overview of the process for  awarding competitive HCOP grants.
When awarding HCOP grants, HRSA had the discretion to consider  additional factors, such as geographic diversity, targeted health  professions, and the allocation of HCOP-funded services and activities  among minority populations who are disadvantaged. According to a HRSA  official responsible for administering the HCOP program, the agency could  have used this discretion to depart from the rank-order list resulting from  the independent review process but did not do so for fiscal years 2002  through 2005. This official said that 80 percent of HCOP program  participants in fiscal year 2004 came from disadvantaged minority groups,  regardless of the entity that received the HCOP grants, and that HRSA had  concluded that no divergence from the rank-order list was required since  the allocation of HCOP-funded activities among minority populations was  consistent with the Public Health Service Act. For fiscal year 2004,  however, HRSA reduced all competitive HCOP grant budgets by   10 percent—an action that enabled the agency to fund five additional  grants, including three at historically black colleges and universities that  would not otherwise have been funded.
section_title: Applications from Minority-Serving Institutions Generally Received Grants in Greater Proportion Than All Applications
paragraphs: For fiscal years 2002 through 2005, HRSA reviewed a total of 439  applications for competitive HCOP grants and awarded 99 HCOP grants.  The number of competitive HCOP grants awarded depended on the  availability of funds each year, and HRSA was unable to fund many high- scoring applications that received the funding preference. Over the 4 fiscal  years, minority-serving institutions submitted 25 percent of the  applications for competitive HCOP grants and received 30 percent of the  awards.
subsections: section_title: Number of Competitive Grants Awarded Depended on Availability of Funds
paragraphs: Both the number of applications and the number of competitive grants  awarded varied from year to year (see table 2). Overall, for fiscal years  2002 through 2005, applications for new HCOP grants outnumbered  applications for competitive continuations by nearly three to one, but  applications for new grants received about the same number of awards as  applications for competitive continuation grants.
The number of competitive grants awarded in a given year depended more  on the availability of funds for competitive HCOP grants than on the  applications’ scores. Each year, the score of the lowest-scoring application  receiving a grant differed little from the score of the next application on  the list, which did not receive a grant. While all applications that received  grants for fiscal years 2002 through 2005 qualified for the funding  preference for comprehensive projects, the preference did not guarantee  that an application would be funded. In some years, applications that  received the funding preference and scored in the 80s (out of 100 possible  points) were not funded. As shown in figure 3, the majority of applications  that were approved for funding by the independent reviewers received the  funding preference, but not all were funded.
section_title: About One-Third of Competitive HCOP Grants Were Awarded to Minority- Serving Institutions
paragraphs: For fiscal years 2002 through 2005, minority-serving institutions submitted  a total of 25 percent of all applications for competitive HCOP grants and  received about 30 percent of awards. Although minority-serving  institutions received awards in greater proportion than their  representation among all applications for HCOP grants over the 4 fiscal  years, the proportions varied from year to year. For fiscal years 2002, 2004,  and 2005, minority-serving institutions were represented among grantees  in the same, or in greater, proportion than they were among applications,  submitting 25–28 percent of applications and receiving 25–35 percent of  grants. Fiscal year 2003 stands out because of the smaller number of  competitive grants awarded; that year, 10 competitive HCOP grants were  awarded, 1 of which was awarded to a minority-serving institution (see  table 3). The smaller number of competitive grants was mainly due to the  relatively high number of noncompetitive continuation grants that  received funding for that fiscal year.
Among minority-serving institutions, historically black colleges and  universities submitted the most applications and received the most  awards, followed by Hispanic-serving institutions (see table 4).
Some entities submitted more than one application over the 4 fiscal years  of our review, and a given entity may have received more than one grant.  For example, an entity may have applied for an HCOP grant for fiscal year  2002 and failed to receive a grant, then tried again in subsequent years. A  new fiscal year 2002 grantee would have had to apply for a competitive  continuation grant for fiscal year 2005 after the end of its 3-year project  period. It is also possible for the same entity to have had more than one  HCOP grant at the same time, provided that each grant had a distinct  purpose and budget.
section_title: Agency Comments
paragraphs: In written comments on a draft of this report (see app. III), HRSA stated  that the report met the goals of describing the award process and outlining  the number and characteristics of HCOP applicants and grantees. HRSA  suggested that, due to the small number of grantees, the summary of  findings on our Highlights page present the numbers, rather than  percentages, of minority institutions that were awarded grants between  2005 and 2006. For the summary, we believe it is appropriate to use  percentages to convey that applications from minority-serving institutions  generally received grants in greater proportion than all applications. As  noted in the draft report, the percentages we present are for the 4-year  period of fiscal years 2002 through 2005. HRSA provided two other  comments suggesting revisions to clarify our discussion, which we  generally incorporated. In addition, HRSA provided technical comments  which we incorporated as appropriate.
We are sending copies of this report to the Administrator of HRSA and  appropriate congressional committees. We will also provide copies to  others upon request. In addition, the report is available at no charge on the  GAO Web site at http://www.gao.gov.
If you or your staff members have any questions about this report, please  contact me at (312) 220-7600 or aronovitzl@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on the  last page of this report. GAO staff who made major contributions to this  report are listed in appendix IV.
section_title: Appendix I: Identification of Minority-Serving Institutions
paragraphs: We determined whether Health Careers Opportunity Program (HCOP)  applicants and grantees were minority-serving institutions by using  statutory definitions, lists of institutions that fall under these statutory  definitions, and data from the Department of Education. The term  “minority-serving institution” refers to an accredited institution of higher  education eligible for federal support under title III or title V of the Higher  Education Act of 1965; this support is administered by the Department of  Education. These institutions include historically black colleges and  universities, American Indian tribally controlled (or tribal) colleges and  universities, Hispanic-serving institutions, Native Hawaiian–serving  institutions, and Alaska Native–serving institutions.
For our review, we defined historically black colleges and universities and  tribal colleges and universities as institutions that met certain statutory  definitions for institutions eligible to receive federal support under title III  of the Higher Education Act of 1965. To identify an HCOP applicant or  grantee as a historically black college or university, we compared a list of  historically black colleges and universities published by the White House  Initiative on Historically Black Colleges and Universities with the data we  obtained from the Health Resources and Services Administration (HRSA)  on HCOP grant applicants and recipients. To identify HCOP applicants and  grantees that were designated as a tribal college or university, we  compared a list published by the White House Initiative on Tribal Colleges  and Universities with the data we obtained from HRSA on HCOP grant  applicants and recipients.
Hispanic-serving institutions, Native Hawaiian–serving institutions, and  Alaska Native–serving institutions are eligible for federal funding under  title III or title V of the Higher Education Act of 1965. Unlike historically  black colleges and universities and tribal colleges and universities,  however, eligibility of these institutions for funding is based on the  percentage of enrolled minority students. As a result, the number of  institutions that qualify as Hispanic-serving institutions, Native Hawaiian– serving institutions, and Alaska Native–serving institutions can vary from  year to year. For our review, we defined Hispanic-serving institutions as  those that received grants through the Developing Hispanic-Serving  Institutions Program under title V of the Higher Education Act of 1965 for  fiscal years 2002 through 2005. That is, we determined an institution’s  status as a Hispanic-serving institution for a particular fiscal year on the  basis of whether the institution had a title V grant that year. To identify  HCOP applicants and grantees that were Hispanic-serving institutions at  the time of our review, we obtained lists of title V grantees for the  Developing Hispanic-Serving Institutions Program from the Department of  Education’s Web site for fiscal years 1999 through 2005. We cross-checked  the title V grantee lists with the membership of the Hispanic Association of  Colleges and Universities and with lists of schools with significant  Hispanic enrollment from the Department of Education’s Office of Civil  Rights. We compared these lists with the data we obtained from HRSA on  HCOP grant applicants and recipients. In addition, we counted all HCOP  applicants and grantees located in Puerto Rico as Hispanic-serving  institutions. Because not all institutions that could be eligible for grants  under title V of the Higher Education Act of 1965 apply for or receive title  V grants, our counts of Hispanic-serving institutions at a given time are  likely to be conservative. Likewise, we defined Native Hawaiian–serving  institutions and Alaska Native–serving institutions as those that were  eligible to receive grants under title III of the Higher Education Act of  1965 and that received such grants for fiscal years 2002 through 2005.
As noted above, the exact number of entities designated as minority- serving institutions may vary from year to year. While we were able to  classify the HCOP applicants and grantees for fiscal years 2002 through  2005, table 5 summarizes the different minority-serving institution  designations and provides approximate counts for fiscal year 2005, the  most recent year for which total counts were available.
section_title: Appendix II: HCOP Competitive Applications and Grants, by Location of Grant Applicant, Fiscal Years 2002 through 2005
paragraphs: Table 6 shows, by location, applications and awards for competitive HCOP  grants for fiscal years 2002 through 2005. The numbers represent  applications, rather than individual applicant entities. An entity may have  applied for a competitive HCOP grant more than once, and a single entity  may have had more than one HCOP grant for separate and distinct HCOP  projects. The locations are those of the grant applicants, although  partnerships may cross state lines and result in HCOP-funded activities  and services in more than one state.
section_title: Appendix III: Comments from the Health Resources and Services Administration
section_title: Appendix IV: Contact and Acknowledgments
subsections: section_title: GAO Contact
section_title: Acknowledgments
paragraphs: In addition to the contact named above, Kim Yamane, Assistant Director;  Matt Byer; Ellen W. Chu; Karlin Richardson; Suzanne Rubins; and   Hemi Tewarson made key contributions to this report.
section_title: Related GAO Products
paragraphs: Health Professions Education Programs: Action Still Needed to Measure  Impact. GAO-06-55. Washington, D.C.: February 28, 2006.
Low-Income and Minority-Serving Institutions: Department of  Education Could Improve its Monitoring and Assistance. GAO-04-961.  Washington, D.C.: September 21, 2004.
Health Professions Education: Clarifying the Role of Title VII and VIII  Programs Could Improve Accountability. GAO/T-HEHS-97-117.  Washington, D.C.: April 25, 1997.