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. 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. 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. 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.” 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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). 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. 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.

Summary: 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. 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.