Health Professional Shortage Areas:

Problems Remain with Primary Care Shortage Area Designation System

GAO-07-84: Published: Oct 24, 2006. Publicly Released: Oct 24, 2006.

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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.

Status Legend:

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  • Review Pending-GAO has not yet assessed implementation status.
  • Open-Actions to satisfy the intent of the recommendation have not been taken or are being planned, or actions that partially satisfy the intent of the recommendation have been taken.
  • Closed-implemented-Actions that satisfy the intent of the recommendation have been taken.
  • Closed-not implemented-While the intent of the recommendation has not been satisfied, time or circumstances have rendered the recommendation invalid.
    • Review Pending
    • Open
    • Closed - implemented
    • Closed - not implemented

    Recommendations for Executive Action

    Recommendation: The Secretary of Health and Human Services should 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.

    Agency Affected: Department of Health and Human Services

    Status: Closed - Implemented

    Comments: HHS published a list of designated HPSAs in the Federal Register on November 3, 2011. An HHS official confirmed that the publication removed the HPSA designations for those HPSAs that no longer met the criteria or that had not provided updated data in support for their designations. Specifically, the official stated that all HPSAs that had a status of P (proposed withdrawal) or N (no new data submitted) from 2002 through September 1, 2011 were withdrawn effective the date of the Federal Register publication.

    Recommendation: The Secretary of Health and Human Services should 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.

    Agency Affected: Department of Health and Human Services

    Status: Closed - Implemented

    Comments: HHS published its proposal to revise the HPSA designation system in the Federal Register on February 29, 2008. In response to the many comments received on the proposed rule, HHS announced in July 2008 that it would issue a revised proposal prior to issuing the final rule.

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