Health Professional Shortage Areas: Problems Remain with Primary Care Shortage Area Designation System
Published: 2006-10-24T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: To identify areas facing shortages of health care providers, the Department of Health and Human Services (HHS) relies on its health professional shortage area (HPSA) designation system. HHS designates geographic, population-group, and facility HPSAs. HHS also gives each HPSA a score to rank its need for providers relative to other HPSAs. The Health Care Safety Net Amendments of 2002 required GAO to report on the HPSA designation system. GAO reviewed (1) the number and location of HPSAs and federal programs that use HPSA designations to allocate resources or provide benefits, (2) available research on HPSA designation criteria and methodology, and (3) the impact of a 2002 provision that automatically designates federally qualified health centers and certain rural health clinics as facility HPSAs. GAO obtained and analyzed HHS's data on primary care HPSA designations as of September 2005 and January 2006 and identified reports on HPSA criteria and methodology through a literature search of peer-reviewed journals and other reports published since 1995.
section_title: What GAO Found
paragraphs: GAO identified more than 5,500 HPSAs designated throughout the United States as of September 2005; multiple federal programs relied on these designations to allocate resources or provide benefits. GAO estimated that slightly more than half of the HPSAs were designated for geographic areas--such as counties or portions of counties--or population groups, such as migrant farmworkers. The remaining HPSAs were designated for facilities, such as rural health clinics. In fiscal year 2005, more than 30 federal programs relied on HPSA designations, and in some cases HPSA scores, to allocate resources or provide benefits. The use of the HPSA designation by numerous federal programs to allocate resources or provide benefits is an incentive for obtaining and retaining a HPSA designation. Published reports have pointed to shortcomings in the methodology used for designating HPSAs. These reports' observations were consistent with findings in GAO's 1995 report, Health Care Shortage Areas: Designations Not a Useful Tool for Directing Resources to the Underserved, (GAO/HEHS-95-200, Sept. 8, 1995), including that HHS's methodology did not account for certain types of primary care providers already serving in a HPSA, which can result in an overstatement of the provider shortage. Recognizing the shortcomings of the current methodology, HHS has been working since 1998 on a proposal to revise the designation system. In addition, some HPSAs that no longer meet the criteria have retained their HPSA designation and possibly received benefits from federal programs that rely on that designation. HHS has not complied since 2002 with the statutory requirement to annually publish a list of designated HPSAs in the Federal Register--which would remove the designations of those HPSAs that are no longer listed. Many federally qualified health centers and rural health clinics did not benefit from automatic designation as facility HPSAs because they were located in geographic or population-group HPSAs. In addition, most of the more than 1,600 federally qualified health centers received HPSA scores associated with the automatic designation that were too low to qualify them for certain federal programs that required a minimum HPSA score in 2005, although they qualified for other programs that did not have such a requirement. Of the 590 rural health clinics that chose to certify that they would treat anyone regardless of ability to pay and, as a result, received automatic designation as facility HPSAs, most also received associated HPSA scores too low to qualify for benefits from certain federal programs that required a higher HPSA score.

section_title: Letter
paragraphs: Many Americans live in areas, such as inner-city neighborhoods or isolated  rural locations, where obtaining health care is difficult because health care  providers are in short supply. To identify areas facing a critical shortage of  providers, the Department of Health and Human Services (HHS) relies on  its health professional shortage area (HPSA) designation system.  Originally created in 1978 to identify areas in need of physicians and other  health care providers from HHS’s National Health Service Corps (NHSC)  programs, HPSA designation is now used by a variety of federal  programs—including programs that provide grants for health professions  education and training or bonus payments under Medicare for physician  services—to allocate resources or provide benefits.
A HPSA can be a distinct geographic area (such as a county), a specific  population group within an area (such as low-income individuals), or a  specific health care facility. Facility HPSAs include federal or state  correctional institutions, as well as federally qualified health centers— facilities that provide primary care services in underserved areas—and  certain rural health clinics—facilities that provide outpatient primary care  services in rural areas. HHS’s Health Resources and Services  Administration (HRSA)—the HHS agency that manages the HPSA  designation system—designates HPSAs based on the ratio of population to  the number of primary care physicians and other factors. HRSA then  assigns each HPSA a score on the basis of specific criteria that ranks its  shortage of primary care providers, or need, relative to other HPSAs.  Some federal health care programs, such as NHSC programs, allocate their  resources on the basis of HPSA scores, not just HPSA designations.
HHS’s criteria and methodology for designating HPSAs has remained  unchanged since October 1, 1993. In 1998, in an effort to improve the way  underserved areas were designated, HHS published a proposal to revise  the HPSA designation system. The department received more than 800  comments on its proposal from individuals and organizations, including  individual physicians, state primary care organizations, and university or  research organizations. These comments raised several issues, such as  whether or how to count nonphysician providers, such as physician  assistants, in the total number of practitioners serving a population; the  potential number of HPSAs that would lose their HPSA designations  because of changes in the designation criteria; and the incorporation of  certain population factors, such as the percentage of elderly and uninsured  individuals, which reflect a population’s ability to access care. In response  to these comments, HHS withdrew its 1998 proposal, and left the existing  HPSA designation system in place while it began working on another  proposal.
The Health Care Safety Net Amendments of 2002 required that we report  on the HPSA designation system and on a provision included in the act  that automatically designates health centers and certain rural health  clinics as facility HPSAs. As discussed with the committees of  jurisdiction, this report discusses (1) the number and location of HPSAs  and the federal programs that use HPSA designations to allocate resources  or provide benefits, (2) available research on the criteria and methodology  used to designate HPSAs, and (3) the impact of the automatic HPSA  designation on health centers and rural health clinics.
To conduct our work, we examined relevant laws, regulations, and HHS  documents related to the HPSA criteria in effect in 2005—criteria that had  remained unchanged since 1993—and reviewed our prior work on the  HPSA designation system. To determine the number of HPSAs, we  interviewed officials from HRSA, who reported that precise, accurate,  historical data on the total number of HPSAs were not available.  Therefore, to estimate the number of HPSAs designated as of September  2005, we designed a methodology that used data from HRSA, including  summary statistics on geographic and population-group HPSA  designations and data files on the facilities that were automatically  designated as HPSAs. We also analyzed a more detailed database of  geographic and population-group HPSAs as of January 2006 in order to  identify (1) the counties in which geographic and population-group HPSAs  were located and (2) the HPSAs that were proposed for having their  designations withdrawn because they no longer met the criteria or did not  provide updated data in support of their designations. After taking steps to  eliminate potential duplications or inconsistencies in the data we used, we  determined that the data were sufficiently reliable for our purposes. To  obtain information on HPSA designations and federal programs that use  HPSA designations, we reviewed Federal Register notices and other  documents obtained from HHS agencies—including HRSA, the Centers for  Medicare & Medicaid Services (CMS), and the Indian Health Service  (IHS)—and reviewed our prior work on these programs.
To identify available research on the criteria and methodology used to  designate HPSAs, we conducted a literature search of reports, including  those published in peer-reviewed journals, issued from January 1, 1995,  through November 1, 2005. We identified other published reports  discussing the HPSA designation methodology, including one by the  Council on Graduate Medical Education (COGME). Of the more than 340  articles, studies, and reports—which we refer to as reports—identified in  the search, we identified 7 that addressed the relationship between key  elements of the HPSA designation criteria, such as income, and primary  care physician supply or shortages, or that addressed factors related to the  HPSA designation methodology. We also interviewed researchers who  have studied primary care provider shortages, as well as HRSA officials  knowledgeable about the HPSA designation system. To review the impact  of the automatic designation on health centers and rural health clinics, we  analyzed HRSA’s data on automatic HPSA designations, including the  HPSA scores associated with automatic designation, and interviewed  HRSA officials and officials from associations representing these types of  facilities. We performed our work from August 2005 through September  2006 in accordance with generally accepted government auditing  standards.
subsections: section_title: Background
paragraphs: Any agency or individual may request a HPSA designation for a geographic  area, population group, or facility. According to HRSA officials, the vast  majority of HPSA designation requests are submitted by state primary care  offices. These requests are received and reviewed by the Shortage  Designation Branch within HRSA. Individual and agency requesters, other  than state primary care offices, are required to submit a copy of their  request for HPSA designation to their state’s primary care office. The state  primary care office solicits comments about the request from state groups,  including the state health department and state professional associations,  and forwards the comments to HRSA. Other interested parties may also  provide comments on the request and submit the comments directly to  HRSA. HRSA’s final designation decision is based on a review of the  request and comments received from the state and other interested parties  (see fig. 1).
HRSA designates three types of HPSAs: geographic, population-group, and  facility. Geographic HPSAs include entire counties, a portion of a county,  or a group of contiguous counties. Population-group HPSAs include  groups, such as migrant farmworkers, low-income urban populations, or  federally recognized Native American Tribes or Alaska Natives, within a  particular geographic area. Facility HPSAs include federal or state  correctional institutions, health centers, and certain rural health clinics.  To receive HPSA designation, the requesting agency or individual must  provide HRSA with information demonstrating that the area, population  group, or facility meets applicable criteria (see fig. 2).
Since 2002, two kinds of facilities—(1) health centers and (2) rural health  clinics that certify that they treat everyone regardless of ability to pay— have been automatically designated as facility HPSAs without going  through the standard request and review process. Health centers include  consolidated health centers, health center look-alikes, and tribal health  centers:  Consolidated Health Centers: These health centers—which include  community health centers, migrant health centers, health centers for the  homeless, and health centers for residents of public housing—receive  grants and grant funding under section 330 of the Public Health Service  Act. Consolidated health centers provide comprehensive community- based primary care services to individuals regardless of their ability to pay  and are required to serve the medically underserved.
Health center look-alikes: These facilities have been determined to meet  all of the requirements necessary to receive a grant under section 330 of  the Public Health Service Act but do not receive such funding.
Tribal health centers: These facilities receive federal support to provide  outpatient health services and are operated by tribes, tribal organizations,  or urban Indian organizations under the Indian Self-Determination Act or  the Indian Health Care Improvement Act.
Rural health clinics are located in rural areas and can operate either  independently or as part of a larger organization, such as a hospital, skilled  nursing facility, or home health agency. Unlike health centers, which are  public or private nonprofit facilities, rural health clinics may function as  for-profit entities. Rural health clinics must offer primarily outpatient  primary medical care, but unlike health centers, they are not required to  serve all individuals regardless of their ability to pay. Therefore, those  rural health clinics that wish to receive automatic facility HPSA  designation must certify to HRSA that they provide services to all  individuals, regardless of their ability to pay, in order to receive the  designation.
After receiving the HPSA designation, each geographic, population-group,  and facility HPSA is scored on a scale of 0 to 25, with higher scores  indicating greater relative need for primary care providers. The HPSA  score is based on four elements, including elements used for HPSA  designation: the ratio of population to primary care physicians (1 to 5  possible points, then doubled), poverty rate (0 to 5 possible points), infant  mortality rate or low birth weight rate (0 to 5 possible points), and travel  time or distance to the nearest available source of primary care (0 to 5  possible points). For a health center or rural health clinic automatically  designated as a facility HPSA, if complete data are not available or HRSA  cannot match the facility to appropriate data to calculate a HPSA score,  the HPSA receives either a score of 0 or a partial score based on the sum  of factors for which data are obtainable. According to HRSA’s data on  health centers and rural health clinics that received automatic designation  as facility HPSAs, 10 percent of these facility HPSAs had a HPSA score of 0  as of September 2005.
HRSA calculates the HPSA score using the information from the HPSA  designation request. For health centers and rural health clinics that receive  automatic facility HPSA designation, HRSA calculates the HPSA score  using nationally available data and approximates the service area of a  health center or rural health clinic by using data on the Primary Care  Service Area in which the facility is located. Any automatically  designated facility HPSA located in a geographic or population-group  HPSA may instead use the HPSA score for that geographic area or  population group, which, according to HRSA officials, is likely to be much  higher than the automatic facility HPSA score. According to HRSA  officials, nationally available data used for automatic facility HPSA scores  are often not as current or as precise as data collected for individual  geographic and population-group HPSA designations.
HHS is required by law to review HPSA designations annually to determine  if the designations remain appropriate in light of the applicable  requirements. Each year, it must also publish a list of designated HPSAs  in the Federal Register. For HPSAs designated through the standard  request and review process, HHS reviews the designations by giving a list  of HPSAs that have been designated for 3 full years to each state and  asking the relevant state groups—including the state’s governor’s office  and state health department—to update the information. HPSA  designations for which data are not provided or that no longer meet the  designation criteria are proposed for withdrawal. A HPSA that is proposed  for withdrawal remains designated as a HPSA until HHS publishes in the  Federal Register either a notification that the HPSA designation has been  withdrawn or an updated list of designated HPSAs that does not include  that HPSA. Before a HPSA designation can be withdrawn, however,  interested parties and groups must be allowed to provide data and  information in support of the designation. A health center or rural health  clinic receiving automatic facility HPSA designation must demonstrate  every 6 years after receiving its automatic designation that it meets the  definition of a HPSA.
section_title: HPSAs Are Located in Every State and Are Used by Multiple Federal Programs
paragraphs: More than 5,500 HPSAs were located throughout the country as of  September 2005. We estimated that over half of these HPSAs were  geographic or population-group HPSAs; the rest were facility HPSAs.  Numerous federal programs have used these HPSA designations to  allocate their programs’ resources or provide benefits, which is an  incentive for obtaining and retaining the HPSA designation.
subsections: section_title: Number and Location of HPSAs
paragraphs: Using HRSA data, we identified 5,594 designated HPSAs as of September  2005. We estimated that slightly more than half (3,032) of these HPSAs  were designated for geographic areas or population groups. HRSA  calculated that geographic and population-group HPSAs needed 6,941  additional full-time primary care physicians to achieve ratios of population  to primary care physicians that would remove the HPSA designations (see  table 1).
Of the 1,646 geographic HPSAs, slightly more than half (831) consisted of  an entire county, and the remainder (815) consisted of other service areas  within counties, such as specific census tracts. As illustrated in figure 3,  geographic and population-group HPSAs designated as of January 2006  were located in 2,494 counties in all 50 states and the District of  Columbia.
We estimated that slightly less than half (2,562) of all HPSAs designated as  of September 2005 were facility HPSAs. Of these, about 63 percent (1,625)  were health centers, about 23 percent (590) were rural health clinics, and  about 14 percent (347) were federal or state correctional institutions (see  fig. 4). Excluded from this count of facility HPSAs were 136 public or  nonprofit medical facilities that HRSA’s data indicated had requested and  received a facility HPSA designation, but that HRSA officials said could be  duplicates of health centers that HRSA’s data showed as having  automatically received a facility HPSA designation. Also excluded were 21  health centers that HRSA’s data identified as health centers for Alaska  Natives that received automatic facility HPSA designations, but that HRSA  and IHS officials said could be duplicates of health centers HRSA’s data  identified as tribal health centers.
As of September 2005, health centers with facility HPSA designations were  located in all 50 states and the District of Columbia. Rural health clinics  with facility HPSA designations were located in 41 states, and federal or  state correctional institutions with facility HPSA designations were  located in 46 states.
section_title: Federal Programs Using HPSA Designations
paragraphs: Although the HPSA designation system was originally used to designate  areas for placement of providers through NHSC programs, the HPSA  designation, and in some cases the HPSA score, have since been used by  more than 30 federal programs to allocate resources or provide benefits. In  fiscal year 2005, NHSC—which received $131 million in funding from  HRSA appropriations—administered four programs that used the HPSA  designation—three of which also used the HPSA score:  NHSC Scholarship Program: NHSC awards scholarships to health  professions students who agree to practice for at least 2 years in a HPSA  after completing training as a primary care physician, nurse practitioner,  nurse-midwife, physician assistant, or other eligible provider. Scholarship  recipients are limited to practicing at NHSC-approved practice sites in  HPSAs with high need, as determined by the HPSA designation score. For  the period July 1, 2005, through June 30, 2006, scholarship recipients  completing training who were primary care physicians were required to  practice in HPSAs with scores of 14 or higher, while those completing  training as nurse practitioners, physician assistants, and nurse-midwives  were required to practice in HPSAs with scores of at least 13, 13, and 8,  respectively. At the end of fiscal year 2005, about 670 NHSC scholarship  recipients, including primary care physicians, nurse practitioners, nurse- midwives, and physician assistants, were practicing in HPSAs to complete  their NHSC service obligations.
NHSC Loan Repayment Program: NHSC repays educational loans of fully  trained health professionals who agree to practice for at least 2 years in a  HPSA. In addition to the practice sites approved for scholarship  recipients, loan repayment recipients—including primary care physicians,  nurse practitioners, physician assistants, nurse-midwives, and other  providers—may practice at NHSC-approved sites in other HPSAs,  including those with lower HPSA scores. Loan repayment awards are  made to providers who practice in higher-scoring HPSAs first, and then to  providers who practice in lower-scoring HPSAs in descending order as  long as program funds are available. Sufficient funds were available for  fiscal years 2003 through 2005 to make awards to all providers with  eligible and complete loan repayment applications, regardless of the  practice location’s HPSA score. At the end of fiscal year 2005, about 1,700  NHSC loan repayment recipients were practicing in HPSAs to complete  their NHSC service obligations.
NHSC State Loan Repayment Program: NHSC provides grants to states to  operate state loan repayment programs. Eligibility requirements and  benefits, such as the maximum amount of loan repayment each year, may  vary from state to state, but state loan repayment recipients must agree to  provide primary health services in a HPSA. At the end of fiscal year 2005,  about 680 NHSC state loan repayment recipients were practicing in HPSAs  under this program.
NHSC Ready Responder Program: Providers—including primary care  physicians, nurse practitioners, physician assistants, and nurses—can  receive salaries, benefits, and moving expenses to serve as commissioned  officers in the U.S. Public Health Service who are assigned by NHSC to  practice for 3 years in the neediest HPSAs. In determining practice  locations for Ready Responders, NHSC gives preference to NHSC- approved sites in HPSAs with high scores. HRSA’s 2004 notice to recruit  providers to participate in this program stated that NHSC Ready  Responders would be part of a mobile team of health professionals who, in  addition to the services they provide to patients at their assigned sites,  might be called upon to respond to regional or national emergencies. At  the end of fiscal year 2005, 56 NHSC Ready Responders were practicing in  HPSAs.
In addition to the 4 NHSC programs, more than 26 other federal programs  have used the HPSA designation to allocate resources or provide  benefits. For example:    CMS’s Medicare Incentive Payment program pays physicians a 10 percent  bonus for services provided to Medicare beneficiaries in a geographic  HPSA. According to CMS’s Office of Financial Management, the Medicare  program paid about $148 million in these bonus payments in fiscal year  2005.
CMS’s Rural Health Clinic program employs special payment rules for the  reimbursement of services provided by rural health clinics under Medicare  and Medicaid, which is an incentive for becoming a rural health clinic. For  example, rural health clinics are reimbursed under a modified cost-based  method of payment under Medicare. For reimbursement purposes, a rural  health clinic must be located in a geographic or population-group HPSA in  a rural area, a rural area designated by a state’s governor (or chief  executive officer) and certified by HHS as an area with a shortage of  personal health services, or a rural area HRSA has designated as a  medically underserved area (MUA).
Federal agencies—including HHS, the Appalachian Regional  Commission, and the Delta Regional Authority—as well as state health  departments, operate programs, called J-1 visa waiver programs, to attract  foreign physicians who have just completed their graduate medical  education in the United States to practice in underserved areas. In  exchange for a commitment to practice for at least 3 years at a facility  located in, or treating residents of, a HPSA, an MUA, or a medically  underserved population (MUP), foreign physicians can receive the benefit  of a waiver of a 2-year foreign residence requirement. Of the federal  agencies administering J-1 visa waiver programs in 2005, HHS required  foreign physicians receiving J-1 visa waivers through its J-1 visa waiver  program to practice in certain health centers, rural health clinics, or other  facilities in HPSAs with a HPSA score of 14 or higher.
More than 15 federal programs that funded health professions education  and training grants in fiscal year 2005 used the HPSA designation to  provide funding preferences to grant applicants. Authorized under title  VII of the Public Health Service Act—with more than $160 million in  funding from HRSA’s fiscal year 2005 appropriations—these programs  provided funding preferences to grant applicants, such as health  professions schools that placed a high or increasing number of graduates  in settings serving medically underserved communities, including HPSAs.  For purposes of the funding preference, the Public Health Service Act  defines medically underserved communities to include areas or  populations that are eligible for HPSA designation, or that meet other  criteria, such as being eligible to be served by a community or migrant  health center.
The use of the HPSA designation by more than 30 federal programs to  allocate resources or provide benefits is an incentive for obtaining and  retaining a HPSA designation, even if the HPSA does not want or need  additional primary care providers. Agencies or individuals requesting  initial designations or continuations of the HPSA designations for  geographic areas, population groups, or facilities may instead want the  designation for other purposes, for example, to be eligible for benefits  such as the 10 percent bonus payment for physician services under CMS’s  Medicare Incentive Payment program. In 1998, COGME reported that one  possible reason that the number of HPSAs had not declined was that “as  the penalty for designation loss has increased, organizations have become  more adept at making the case for retaining or attaining this coveted  status.”
section_title: Research Points to Shortcomings with Designation Methodology
paragraphs: Of the reports published since 1995 that addressed the criteria or  methodology used to designate HPSAs, we identified one that supported  one key element of the criteria and six that pointed to shortcomings in the  designation methodology. These six reports were consistent with what we  reported in 1995. HHS officials have acknowledged these shortcomings  and the department has been working on a proposal for revising the HPSA  designation system since 1998, which, as of September 2006, had not been  finalized. Another problem we identified in 1995 that persists in 2006 is  HRSA’s lack of timely removal of HPSA designations that no longer meet  the designation criteria.
Of the seven reports we identified as research on the HPSA criteria or  methodology, one of the peer-reviewed reports addressed the relationship  between one key element of the HPSA designation criteria and primary  care physician supply. This report found a positive association between  primary care physician supply and an area’s income—one of the elements  of the HPSA criteria used to demonstrate unusually high needs for primary  care services. Specifically, the researchers found that areas with higher  incomes had a greater number of primary care physicians than areas with  lower incomes.
Other published reports have, however, pointed to shortcomings in the  methodology HRSA uses to designate HPSAs—specifically that the system  has not effectively identified areas with primary care shortages or helped  target federal resources to benefit those who are underserved. For  example, reports—including one we issued in 1995—have noted that  HRSA’s designation methodology does not accurately identify those  providers available to furnish primary health care services. As a result,  the HPSA methodology can overstate the need for additional primary care  providers, limiting the usefulness of the HPSA designation system as a  screen to identify which communities should be eligible for additional  program benefits. Since 1995, we and others have reported problems with  HRSA’s exclusion of several categories of primary care providers when  calculating the available primary care providers. For example, in our 1995  report, we estimated that the reported need for additional providers in  1994 would have been reduced by up to 50 percent if certain categories of  primary care physicians and nonphysician providers—which were  excluded by HRSA—had been included in the HPSA calculations. In total,  we estimated that 2,539 primary care physicians already providing services  in shortage areas (including NHSC physicians and foreign physicians with  J-1 visa waivers) and other categories of providers who deliver primary  care services in HPSAs (including physician assistants and nurse- midwives) were excluded by HRSA in 1994.
Reports have also concluded that some of the geographic areas that HRSA  evaluates for designation—that is, those based on county boundaries— may not always provide a realistic reflection of an area’s health care  needs. For these HPSA designation requests, measuring the availability of  primary care physicians only in the county where individuals live may  underestimate certain residents’ access to medical care. For example,  two reports we identified discussed the likelihood of people crossing  county lines to obtain health care services when these services were not  available in their community. In one report, researchers evaluated the  relationship between health status and medical care resources and found  that individuals aged 64 years or younger living in nonmetropolitan areas  reported better health when there was greater physician supply in the  county where they lived and adjoining counties. According to these  researchers, the results suggested that younger individuals in  nonmetropolitan areas were willing and able to cross county lines to  obtain health care.
Researchers have also noted that the HPSA designation methodology  favors those states or areas that have experience in completing and  submitting a HPSA designation request. One team of researchers reported  that officials in certain states and localities were effective in identifying  areas that would qualify for a HPSA designation and in providing timely  and appropriate data for the request, whereas other areas were unable to  navigate the process as effectively. The researchers observed that certain  areas were more likely to have HPSA designations than others— independent of the actual local situation.
Recognizing the shortcomings in the HPSA designation system identified  by available research and our prior work, HHS has been working on a  proposal for a revised designation system since 1998. According to HRSA  officials, the proposal incorporates factors to account for all primary care  providers in an area—including foreign physicians with J-1 visa waivers,  NHSC physicians, and nurse practitioners and physician assistants—and  includes the creation of a master database to house national data relevant  to HPSA criteria. As of September 2006, this proposal was in the  department’s clearance process.
Another problem we identified in 1995, that remains a problem in 2006, is  that HRSA does not review designated HPSAs and subsequently remove  the designation of those areas, population groups, or facilities that no  longer meet the HPSA criteria in a timely manner. While we did not audit  HRSA’s process for periodically reviewing HPSAs, in August 2005, the HHS  Office of Inspector General reported that as of 2003, HRSA had not  conducted timely reviews of HPSA designations. In the agency’s  comments that were included in the August 2005 report, HRSA  acknowledged this problem, stating that the agency was unable to  complete the review of designated HPSAs for continued eligibility in less  than 3 years because of resource limitations. As of September 2006, we  found that although HHS is required to publish a list of designated HPSAs  in the Federal Register by July 1 of each year—thereby removing the  designation of any HPSAs that were proposed for withdrawal that are not  published—the department has not done so since February 2002. HRSA  officials told us in June 2006 that the department has not published a list of  HPSAs in the Federal Register for more than 4 years because of difficulties  with computer programming, but the agency hoped to resolve those issues  and to forward an updated list for publication by fall 2006. Meanwhile,  those HPSAs that were proposed for withdrawal because they no longer  meet the HPSA criteria have retained their HPSA designation. As a result,  federal programs that use the HPSA designation, such as the Medicare  Incentive Payment program or HRSA’s health professions education and  training programs, may have been allocating resources or providing  benefits to areas, population groups, or facilities that no longer meet the  HPSA criteria.
section_title: Many Health Centers and Rural Health Clinics Did Not Benefit from Automatic HPSA Designation
paragraphs: Many health centers and rural health clinics did not benefit from  automatic designation as facility HPSAs because they were located in  geographic or population-group HPSAs. Most health centers also received  a HPSA score associated with the automatic designation that was too low  to qualify them for programs that required a minimum HPSA score in 2005,  although they qualified for programs that did not have such a requirement.  Of the relatively few rural health clinics that chose to certify that they  would treat anyone regardless of ability to pay and, as a result, received  the automatic designation as facility HPSAs, most also received scores too  low to qualify for benefits from certain programs that required a higher  HPSA score.
subsections: section_title: Relatively Few Health Centers Had HPSA Scores High Enough to Obtain Providers through Certain Federal Programs
paragraphs: For health centers that were located in a geographic or population-group  HPSA, automatic designation as a facility HPSA provided no benefit unless  the HPSA score associated with automatic designation was higher than the  score for the geographic or population-group HPSA in which they were  located. According to the National Association of Community Health  Centers, health centers had advocated for automatic HPSA designation  because it would allow those not located in geographic or population- group HPSAs to be eligible for providers from NHSC. Although limitations  in HRSA’s data prevented us from measuring the precise impact of the  automatic HPSA designation on health centers, HRSA officials estimated  that about half of the health centers that received automatic designation as  a facility HPSA in 2002 were located in a geographic or population-group  HPSA and therefore did not receive this benefit.
As of September 2005, 73 (less than 5 percent) of the 1,625 health centers  that had received automatic designation as facility HPSAs had an  associated HPSA score high enough to qualify for a physician through the  NHSC Scholarship Program or HHS’s J-1 visa waiver program. These  health centers received a HPSA score of 14 or higher—the HPSA score  required by these programs for physician placement (see fig. 5). Eighty-six  (about 5 percent) of the 1,625 health centers with automatic facility HPSA  designation received a HPSA score of 13 or higher—the HPSA score  required by the NHSC Scholarship Program to qualify for placement of a  nurse practitioner or physician assistant.
In contrast, automatic facility HPSA designation made health centers  eligible, regardless of HPSA score, to apply in 2005 for a physician or other  health care provider through the NHSC Loan Repayment Program.  According to an official with the National Association of Community  Health Centers, health center officials were pleased with this benefit but  also viewed it with caution because NHSC loan repayment awards are  made first to providers who agree to practice in higher-scoring HPSAs and  then to providers who agree to practice in lower-scoring HPSAs, in  decreasing order of HPSA score. Although NHSC had sufficient funding for  all qualifying loan repayment applicants from 2003 through 2005, health  center officials were concerned that in future years, NHSC funding may be  insufficient to sustain this benefit for health centers with relatively low  HPSA scores.
section_title: Few Rural Health Clinics Have Received Automatic HPSA Designation as Facility HPSAs
paragraphs: As of September 2005, 590 (16 percent) of the 3,637 rural health clinics in  the United States had received automatic designation as facility HPSAs. To  receive automatic designation, rural health clinics, unlike health centers,  must certify that they provide health care services regardless of an  individual’s ability to pay. To qualify for automatic HPSA designation,  some rural health clinics—including those that are for-profit entities— would have to restructure their billing practices, and according to officials  at the National Association of Rural Health Clinics and HRSA’s Office of  Rural Health Policy, it may not be in their interest to do so.
As with health centers, the main benefit cited by officials at the Office of  Rural Health Policy of automatic HPSA designation for rural health clinics  is to be eligible for NHSC physicians or other primary care providers.  Rural health clinics that were located in geographic or population-group  HPSAs would not benefit from automatic designation unless the  associated HPSA score was higher than the score for the geographic or  population-group HPSAs in which they were located. Data were not  available to determine how many of the 590 rural health clinics with  automatic facility HPSA designations were located in geographic or  population-group HPSAs before the 2002 provision was implemented. An  official at the National Association of Rural Health Clinics reported,  however, that a recent study estimated that over 70 percent of all rural  health clinics—including those that did not receive the automatic facility  HPSA designation—were located in geographic HPSAs before 2002 and  were therefore already eligible for federal programs requiring HPSA  designation.
As of September 2005, less than 1 percent of the 590 rural health clinics  that had received automatic designation as facility HPSAs had associated  HPSA scores of 14 or higher needed to qualify for a physician through the  NHSC Scholarship Program or HHS’s J-1 visa waiver program (see fig. 6).  About 1 percent received a HPSA score of 13 or higher—the HPSA score  required by the NHSC Scholarship Program to qualify for a nurse  practitioner or physician assistant. Like health centers with lower HPSA  scores, rural health clinics automatically designated as facility HPSAs but  scoring lower than 14 could recruit a physician or other provider through  the NHSC Loan Repayment Program.
section_title: Conclusions
paragraphs: Many federal programs continue to rely on HPSA designations to allocate  federal resources or provide benefits, even though shortcomings we and  others have reported since 1995 have not been addressed. In particular,  the omission of important categories of primary care providers—such as  foreign physicians with J-1 visa waivers and nonphysician primary care  providers—from calculations for HPSA designation can overstate the need  for additional primary care providers. Although HHS has recognized the  need for improvements and has been working since 1998 on a proposal to  revise the HPSA designation system, it remains to be seen when HHS will  make such improvements and what changes will be made. In addition,  HRSA has not regularly removed the HPSA designation of those areas,  population groups, or facilities that no longer meet the designation  criteria.
Available information suggests that the provision to automatically  designate health centers and certain rural health clinics as facility HPSAs  has benefited a relatively small number of these facilities. The precise  impact of the provision could not be measured, however, because of  limitations with available HHS data. For example, the available data did  not include sufficient geographic information to determine which of these  facilities were located in geographic or population-group HPSAs before  receiving automatic designation as facility HPSAs.
section_title: Recommendations for Executive Action
paragraphs: We recommend that the Secretary of Health and Human Services take the  following two actions: (1) publish a list of designated HPSAs in the Federal  Register or otherwise remove, through Federal Register notification, the  HPSA designations for those HPSAs that no longer meet the criteria or  have not provided updated data in support of their designations and   (2) complete and publish HHS’s proposal to revise the HPSA designation  system and address the shortcomings that have been identified in the  current methodology for designating HPSAs.
section_title: Agency Comments
paragraphs: We received comments on a draft of this report from HHS (see app. V).  The department generally agreed with our findings and concurred with  both recommendations. Specifically, the department agreed that a more  timely publication of the Federal Register listing of designated HPSAs is  necessary to ensure that only those areas meeting the regulations remain  designated, and stated that HRSA should publish lists of HPSAs or HPSA  withdrawals to ensure that designations that have already been proposed  for withdrawal are actually withdrawn. The department also noted that it  is proposing a change in the process for withdrawing HPSA designations,  but it did not provide any details on this proposal. HHS also agreed with  our recommendation that the department complete and publish its  proposal to revise the HPSA designation system. HHS stated that this  proposal would address shortcomings that we identified in this and  previous reports and would also affect the regulations governing MUA and  MUP designations.
HHS also commented on our finding that many health centers and rural  health clinics did not benefit from automatic designation as facility HPSAs.  Specifically, HHS stated that our draft report provided a somewhat  misleading assessment of the impact of the automatic designation process  and the department provided additional information on NHSC placements  in automatically designated HPSAs in 2005. Our draft report stated that  few health centers had HPSA scores associated with automatic  designation that were high enough to qualify for a physician through the  NHSC Scholarship Program, but that all health centers that received  automatic designation as HPSAs, even those with lower HPSA scores,  could apply in 2005 for a health care provider through the NHSC Loan  Repayment Program. The data the department provided on NHSC  placements in automatically designated health centers were actually  consistent with the statement in our draft report. HHS’s data, which HHS  officials said included both primary care and nonprimary care providers,  showed that of 216 NHSC providers placed in health centers, relatively few  (less than 5 percent) were placed through the NHSC Scholarship Program  and the NHSC Ready Responder Program (less than 1 percent), whereas  the vast majority (more than 95 percent) were placed through the NHSC  Loan Repayment Program. According to HRSA officials, data for primary  care provider placements (which were not included in the department’s  comments), showed a similar distribution between the three NHSC  programs for 155 primary care NHSC placements in health centers in 2005.  In its comments, HHS also provided information on the process for scoring  automatically designated HPSAs and on NHSC and J-1 visa waiver  programs. In response, we added information on J-1 visa waiver programs  administered by federal agencies other than HHS and by state health  departments.
Finally, HHS suggested that we clarify that our scope was limited to  primary care HPSAs. We made revisions to the report to highlight that our  review only examined primary care HPSA designations.
The department also provided technical comments, which we  incorporated as appropriate.
We are sending copies of this report to the Secretary of Health and Human  Services, the Administrator of HRSA, the Administrator of CMS, and to  appropriate congressional committees. We will also provide copies to  others upon request. In addition, the report will be available at no charge  on the GAO Web site at http://www.gao.gov.
If you or your staff 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 members who made contributions to  this report are listed in appendix VI.
section_title: Appendix I: Scoring of Health Professional Shortage Areas
paragraphs: Each designated health professional shortage area (HPSA) receives a  score that the Department of Health and Human Services’s (HHS) Health  Resources and Services Administration (HRSA) uses to rank its shortage  of primary care providers, or need, relative to other HPSAs. The HPSA  score is used by some federal programs, such as the National Health  Service Corps (NHSC) Scholarship Program, which requires participants  to practice in locations with higher HPSA scores. The scores, ranging from  0 to 25, are based on four factors, for which each HPSA is given a certain  number of points (see fig. 7). To calculate a HPSA score, points for the  population–to–primary care physician ratio, ranging from 1 to 5 points, are  doubled and then summed with the points for each of the other three  factors. For health centers and rural health clinics receiving automatic  designation as facility HPSAs, if complete data are not available, or if  HRSA cannot match the facility to appropriate data to calculate a HPSA  score, the HPSA receives either a score of 0 or a partial score based on the  sum of factors for which data are obtainable.
section_title: Appendix II: Medically Underserved Area or Population Designations and Medically Underserved Community Definition
paragraphs: Medically underserved areas (MUA) and medically underserved  populations (MUP) generally are areas, or populations within areas, that  are designated by HHS’s HRSA as having a shortage of health care  services. The MUA and MUP designations were developed about the same  time as the HPSA designation system but independently from it.  Authorized by the Health Maintenance Organization Act of 1973, MUA and  MUP designations have been used for identifying areas eligible to  participate in the consolidated health center program. That is, in order to  receive health center grant funding as a community health center, migrant  health center, or a center serving residents of public housing or the  homeless, the health center must be located in or serve the residents of an  MUA or MUP.
MUAs are designated for the entire population of a particular geographic  area. MUP designations are limited to particular groups of underserved  people within an area. Individual facilities are not eligible for MUA or MUP  designations as they are under the HPSA designation system. As of  September 2005, HRSA had designated 3,443 geographic areas as MUAs  and 488 population groups as MUPs.
HRSA designates MUAs and MUPs on the basis of four factors of health  service need, the first three of which are also used for HPSA designation  or scoring:  ratio of population to number of primary care physicians,   percentage of the population with incomes below the federal poverty level,    percentage of population aged 65 or over.
To determine if an area meets the criteria to be designated as an MUA or if  a population within an area meets the criteria to be designated as an MUP,  each factor is assigned a weighted value, and these values are summed to  obtain a combined score. This score is used to determine if an area or  population can be designated as an MUA or MUP. Areas and populations  in the country are ranked using this score to determine their order of need  of health services. Areas and populations with scores at or below 62 (the  median score that was calculated for all U.S. counties in 1975 for the four  criteria) are designated MUAs or MUPs. Those populations within areas  with scores above 62 may still be designated as MUPs if they demonstrate  that unusual local conditions impede access to or the availability of  personal health services. Such requests must be documented and  recommended by the state chief executive officer and the responsible  local officials.
One of the ways in which MUAs and MUPs differ from HPSAs is that MUA  and MUP designations are not required to be regularly updated. According  to a HRSA official, some areas with MUA or MUP designations have not  been reviewed since the 1980s. In 1998, HHS published a proposal in the  Federal Register to revise the MUA and MUP designations and combine  them with the HPSA designation system. The department received over  800 comments on the proposal; subsequently, HHS withdrew the proposal  and began working on another one, which, as of September 2006, was in  the department’s clearance process.
Another term—medically underserved community—is used to identify  underserved areas for purposes of funding preferences for health  professions education and training programs authorized under title VII of  the Public Health Service Act. A medically underserved community is  defined as an urban or rural area or population that  is eligible for HPSA designation;  is eligible to be served by a community health center, migrant health  center, or a grantee serving residents of public housing or the homeless;   has a shortage of personal health services, as determined under criteria  issued by the Secretary of Health and Human Services under section  1861(aa)(2) of the Social Security Act (relating to rural health clinics); or is designated by a state governor (in consultation with the medical  community) as a shortage area or medically underserved community.
In fiscal year 2005, 15 programs authorized under title VII, with funding of  more than $160 million, provided funding preferences for any qualified  applicant, such as a health professions school, that had a high rate for  placing graduates in practice settings having the principal focus of serving  residents of medically underserved communities or that achieved a  significant increase in the rate of placing graduates in such settings during  the previous 2-year period.
In addition, two nursing traineeship programs authorized under title VIII of  the Public Health Service Act used the medically underserved community  definition in providing a funding preference to grant applicants. Title VIII  provides a funding preference that includes nursing workforce grant  applicants with projects that will substantially benefit rural or underserved  populations. For purposes of this statutory funding preference for two  title VIII programs—the Advanced Education Nursing Traineeship  Program and Nurse Anesthetist Traineeship Program—HHS used  established clinical sites identified under the definition of medically  underserved community as proxies for rural and underserved populations.
In fiscal year 2005, these two programs authorized under title VIII had  about $17 million in funding.
section_title: Appendix III: Scope and Methodology
paragraphs: To conduct our work, we examined relevant laws, regulations, and HHS  documents related to the HPSA criteria and designation methodology that  were in effect in 2005 for primary care HPSAs, and reviewed our prior  work on the HPSA designation system.
To determine the number of HPSAs, we interviewed officials from HRSA,  who reported that precise, accurate, historical data on the total number of  HPSAs were not available. Therefore, we designed a methodology that  HRSA officials confirmed was reasonable for estimating the number of  HPSAs designated as of September 2005. We used the following HRSA data  sources for our methodology:    For geographic and population-group HPSAs, we obtained and analyzed  summary statistics on HPSA designations as of September 2005 from the  Shortage Designation Branch within HRSA’s Bureau of Health Professions.
For facility HPSAs that were federal or state correctional institutions and  public or nonprofit medical facilities, we reviewed a more detailed HRSA  database of HPSAs designated as of September 2005, downloaded from  HRSA’s Geospatial Data Warehouse.
For facility HPSAs that were health centers and rural health clinics with  automatic facility HPSA designations, we analyzed HRSA’s data files of  facilities with automatic HPSA designations as of September 2005.
We also analyzed HRSA data on the HPSA scores of health centers and  rural health clinics that received automatic HPSA designation to determine  which of these facilities qualified for federal programs that required a  minimum HPSA score as of September 2005. In addition, we reviewed data  as of January 2006 downloaded from HRSA’s Geospatial Data Warehouse  to identify the locations of geographic and population-group HPSAs and  the HPSAs that were proposed to have their HPSA designations withdrawn  because they no longer met the criteria or did not provide updated data in  support of their designations.
We performed reliability checks on the HRSA data to identify potential  duplicate entries or inconsistencies in the data—for example,  inconsistencies between HRSA’s published summary statistics and our  analysis summarizing the data from HRSA’s Geospatial Data Warehouse— and interviewed HRSA officials, Indian Health Service (IHS) officials, and  officials from associations representing health centers and rural health  clinics about the data. We accounted for limitations in the data by  excluding from our analysis the lists of two categories of facility HPSAs— public or nonprofit medical facilities and Alaska Native health centers— that HRSA officials stated could have been duplicates of facilities in  HRSA’s data of health centers that received automatic HPSA designation  and that HRSA had not yet identified as duplicates and removed from its  data. In total, we excluded 136 public or nonprofit medical facilities and  21 Alaska Native health centers. After taking these steps, we determined  that the data were sufficiently reliable for our purposes.
To obtain information on HPSA designation and federal programs that use  HPSA designations, we reviewed Federal Register notices, laws,  regulations, and documents from HHS’s Centers for Medicare & Medicaid  Services (CMS), HRSA, and IHS, including HRSA’s National Health Service  Corps (NHSC) summaries of the NHSC programs’ field strength at the end  of fiscal year 2005, and we reviewed our prior work on these programs.
To identify available research on the criteria used to designate HPSAs  since we last reported on the criteria in 1995, we conducted a literature  search of articles, studies, and reports—which we call reports—issued  from January 1, 1995, through November 1, 2005. We focused our review  on the HPSA criteria that were in effect both in 2002 when the Health Care  Safety Net Amendments were enacted and at the time of our review. We  performed the literature search of peer-reviewed reports using the  ProQuest search engine and keywords that were related to the following  key elements of the HPSA designation criteria, including factors for  determining areas with unusually high needs for primary medical care  services:ratio of population to primary care physicians, indicators of the population with incomes below the poverty level (poverty  or income),   distance to health care services, and    birth rate.
We also identified reports published during that time frame related to the  HPSA criteria or methodology from the bibliographies of relevant reports,  recommendations from experts we interviewed, and our prior work. We  did not independently assess the methods used in the reports we located.
Of the more than 340 reports located through the search, we identified 12  reports that we determined to be potentially relevant. After reviewing  these 12 reports, we found 1 report in a peer-reviewed journal published  from January 1, 1995, through November 1, 2005, that addressed the  relationship between one of the key elements of the HPSA designation  criteria (income) and primary care physician shortages or supply. We  selected this report because it met the following criteria, in addition to the  criteria outlined above:    The report assessed the relationship between at least one key element of  the HPSA designation criteria and primary care physician shortages or  supply at the county, metropolitan statistical area, health service area, or  other local level.
The report used a definition of primary care similar to the definition used  for the HPSA designation (e.g., general or family practice, general internal  medicine, pediatrics, and obstetrics and gynecology).
Of the 12 reports reviewed, 6 reports discussed aspects of the  methodology used to designate HPSAs: 1 issued by the Council on  Graduate Medical Education (COGME), 1 issued by the Cecil G. Sheps  Center for Health Services Research at the University of North Carolina at  Chapel Hill, and 4 published in peer-reviewed journals.
To review the impact of the automatic designation on health centers and  rural health clinics as facility HPSAs, we analyzed HRSA’s data on  automatic HPSA designations and their associated scores. We also  analyzed data on rural health clinics prepared by the Cecil G. Sheps Center  for Health Services Research at the University of North Carolina at Chapel  Hill for HRSA’s Office of Rural Health Policy, which used 2003 and 2004  CMS data on rural health clinics and 2005 HRSA data on HPSAs. However,  limitations in these data prevented us from determining exactly how many  health centers and rural health clinics benefited when all health centers  and certain rural health clinics received automatic designation as a result  of the provision included in the Health Care Safety Net Amendments of  2002. For example, the available data did not include sufficient geographic  information to determine which of these facilities were located in  geographic or population-group HPSAs before receiving automatic  designation as facility HPSAs. Because of the data limitations, we also  interviewed HHS officials in HRSA’s Office of Rural Health Policy and  Bureau of Primary Health Care, as well as officials from the National  Association of Community Health Centers and the National Association of  Rural Health Clinics, to discuss the impact of the automatic designation.
We performed our work from August 2005 through September 2006 in  accordance with generally accepted government auditing standards.
section_title: Appendix IV: Federal Programs Using Health Professional Shortage Area and Other Designations of Underservice
paragraphs: Various federal programs have used the HPSA, MUA, MUP or other  designations, such as medically underserved communities, to allocate  resources, such as scholarships or grants, or to provide benefits, such as  the waiver of requirements associated with a foreign physician’s visa (see  table 2).
section_title: Appendix V: Comments from the Department of Health and Human Services
section_title: Appendix VI: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Acknowledgments
paragraphs: In addition to the person named above, Kim Yamane, Assistant Director;  Ellen W. Chu; Jennifer DeYoung; and Julian Klazkin made key  contributions to this report.
section_title: Related GAO Products
paragraphs: Foreign Physicians: Preliminary Findings on the Use of J-1 Visa  Waivers to Practice in Underserved Areas. GAO-06-773T. Washington,  D.C.: May 18, 2006.
Health Professions Education Programs: Action Still Needed to Measure  Impact. GAO-06-55. Washington, D.C.: February 28, 2006.
Health Centers: Competition for Grants and Efforts to Measure  Performance Have Increased. GAO-05-645. Washington, D.C.: July 13,  2005.
Health Centers and Rural Clinics: State and Federal Implementation  Issues for Medicaid’s New Payment System. GAO-05-452. Washington,  D.C.: June 17, 2005.
Health Workforce: Ensuring Adequate Supply and Distribution Remains  Challenging. GAO-01-1042T. Washington, D.C.: August 1, 2001.
Health Care Access: Programs for Underserved Populations Could Be  Improved. GAO/T-HEHS-00-81. Washington, D.C.: March 23, 2000.
Physician Shortage Areas: Medicare Incentive Payments Not an  Effective Approach to Improve Access. GAO/HEHS-99-36. Washington,  D.C.: February 26, 1999.
Health Care Access: Opportunities to Target Programs and Improve  Accountability. GAO/T-HEHS-97-204. Washington, D.C.: September 11,  1997.
Rural Health Clinics: Rising Program Expenditures Not Focused on  Improving Care in Isolated Areas. GAO/T-HEHS-97-65. Washington, D.C.:  February 13, 1997.
National Health Service Corps: Opportunities to Stretch Scarce Dollars  and Improve Provider Placement. GAO/HEHS-96-28. Washington, D.C.:  November 24, 1995.
Health Care Shortage Areas: Designations Not a Useful Tool for  Directing Resources to the Underserved. GAO/HEHS-95-200.Washington,  D.C.: September 8, 1995.