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entitled 'Health Professional Shortage Areas: Problems Remain with 
Primary Care Shortage Area Designation System' which was released on 
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Report to Congressional Committees: 

United States Government Accountability Office: 

GAO: 

October 2006: 

Health Professional Shortage Areas: 

Problems Remain with Primary Care Shortage Area Designation System: 

Health Professional Shortage Areas: 

GAO-07-84: 

GAO Highlights: 

Highlights of GAO-07-84, a report to congressional committees 

Why GAO Did This Study: 

To identify areas facing shortages of health care providers, 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. 

What GAO Found: 

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. 

What GAO Recommends: 

GAO recommends that HHS 
(1) remove the designations of HPSAs that no longer qualify by 
publishing a list of designated HPSAs in the Federal Register and (2) 
complete and publish HHS’s proposal to revise the HPSA designation 
system. HHS concurred with both recommendations. 

[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-84]. 

To view the full product, including the scope and methodology, click on 
the link above. For more information, contact Leslie G. Aronovitz at 
(312) 220-7600 or aronovitzl@gao.gov. 

[End of Section] 

Contents: 

Letter: 

Results in Brief: 

Background: 

HPSAs Are Located in Every State and Are Used by Multiple Federal 
Programs: 

Research Points to Shortcomings with Designation Methodology: 

Many Health Centers and Rural Health Clinics Did Not Benefit from 
Automatic HPSA Designation: 

Conclusions: 

Recommendations for Executive Action: 

Agency Comments: 

Appendix I: Scoring of Health Professional Shortage Areas: 

Appendix II: Medically Underserved Area or Population Designations and 
Medically Underserved Community Definition: 

Appendix III: Scope and Methodology: 

Appendix IV: Federal Programs Using Health Professional Shortage Area 
and Other Designations of Underservice: 

Appendix V: Comments from the Department of Health and Human Services: 

Appendix VI: GAO Contact and Staff Acknowledgments: 

Related GAO Products: 

Tables: 

Table 1: Number of, Population in, and Physicians Needed in Geographic 
and Population-Group HPSAs, September 2005: 

Table 2: Programs and Administering Agencies That Used HPSA, MUA, MUP 
or Other Designations to Allocate Resources or Provide Benefits in 
Fiscal Year 2005: 

Figures: 

Figure 1: HPSA Designation Request and Review Process, 2005: 

Figure 2: Types of HPSAs and Criteria Used to Designate Them, 2005: 

Figure 3: U.S. Counties with Geographic and Population-Group HPSAs, 
January 2006: 

Figure 4: Types of Facility HPSAs, September 2005: 

Figure 5: Distribution of HPSA Scores among Health Centers 
Automatically Designated as Facility HPSAs, September 2005: 

Figure 6: Distribution of HPSA Scores among Rural Health Clinics 
Automatically Designated as Facility HPSAs, September 2005: 

Figure 7: Scoring of HPSAs, 2005: 

Abbreviations: 

CMS: Centers for Medicare & Medicaid Services: 
COGME: Council on Graduate Medical Education: 
HHS: Department of Health and Human Services: 
HPSA: health professional shortage area: 
HRSA: Health Resources and Services Administration: 
IHS: Indian Health Service: 
MUA: medically underserved area: 
MUP: medically underserved population: 
NHSC: National Health Service Corps: 
USCIS: U.S. Citizenship and Immigration Services: 
VA: Department of Veterans Affairs: 

United States Government Accountability Office: 
Washington, DC 20548: 

October 24, 2006: 

The Honorable Michael B. Enzi: 
Chairman: 
The Honorable Edward M. Kennedy: 
Ranking Minority Member: 
Committee on Health, Education, Labor, and Pensions: 
United States Senate: 

The Honorable Richard Burr: 
Chairman: 
Subcommittee on Bioterrorism and Public Health Preparedness: 
Committee on Health, Education, Labor, and Pensions: 
United States Senate: 

The Honorable Joe Barton: 
Chairman: 
The Honorable John D. Dingell: 
Ranking Minority Member: 
Committee on Energy and Commerce: 
House of Representatives: 

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.[Footnote 1] 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.[Footnote 2] 

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[Footnote 3]--and certain rural health clinics--facilities that 
provide outpatient primary care services in rural areas.[Footnote 4] 
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.[Footnote 5] 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.[Footnote 6] 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.[Footnote 7] In 1998, in an effort to 
improve the way underserved areas were designated, HHS published a 
proposal to revise the HPSA designation system.[Footnote 8] 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.[Footnote 9] 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.[Footnote 10] 

Results in Brief: 

We 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. We estimated 
that slightly more than half of the HPSAs were designated for 
geographic areas or population groups, and these geographic and 
population-group HPSAs were located in all 50 states and the District 
of Columbia. Facility HPSAs, which accounted for slightly less than 
half of the total number of HPSAs, were also located in every state and 
the District of Columbia. In fiscal year 2005, more than 30 federal 
programs--including programs administered by HRSA, CMS, and federal 
agencies outside of HHS--relied on HPSA designations and, in some 
cases, HPSA scores, to allocate resources or provide benefits. These 
included NHSC programs that award scholarships or educational loan 
repayment to students and health professionals in exchange for a 
commitment to practice in HPSAs for at least 2 years. Other programs 
relying on HPSA designations to allocate resources or provide benefits 
included programs that pay physicians bonus payments for services 
provided to Medicare beneficiaries in geographic HPSAs and programs 
that waive certain requirements for foreign physicians if they agree to 
practice in HPSAs or other underserved areas of the United States. 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. 

Of the seven reports we identified that discuss the criteria and 
methodology used to designate HPSAs, one supported a relationship 
between a key element of the HPSA criteria and primary care physician 
supply, while the remaining six pointed to shortcomings in the 
methodology. The one report we identified that supported a key element 
of the criteria found that areas with higher incomes had more primary 
care physicians than areas with lower incomes. The other six reports 
included observations that were consistent with what we reported in 
1995, including the fact that the HPSA designation methodology does not 
account for the presence of certain types of primary care providers in 
a HPSA, which can result in an overstatement of the shortage of primary 
care providers. Researchers have highlighted other problems in the 
methodology used to designate HPSAs, such as relying on geographic 
boundaries that do not necessarily reflect areas' health care needs. 
Recognizing the shortcomings of the current methodology, HHS has been 
working since 1998 on a proposal to revise the HPSA designation system, 
which, as of September 2006, was in the department's clearance process. 
In 1995, we reported on an additional problem involving the timeliness 
with which HRSA identified and removed the HPSA designations of those 
areas, population groups, and facilities that no longer met the HPSA 
criteria--a problem that has continued in recent years. For example, in 
2005, the HHS Office of Inspector General reported that, as of 2003, 
HRSA had not reviewed HPSA designations in a timely manner. In 
addition, we found that since 2002, HHS has not complied with the 
statutory requirement to annually publish a list of designated HPSAs in 
the Federal Register or otherwise remove the HPSA designations for 
those HPSAs that either no longer meet the criteria or have not 
provided updated data in support of their designations. As a result, 
some HPSAs that no longer meet the criteria have retained their HPSA 
designations and possibly received benefits from federal programs that 
rely on the designation for allocating resources. 

Automatic HPSA designation of health centers and certain rural health 
clinics as facility HPSAs provided little or no benefit for many of 
these facilities. For health centers and rural health clinics located 
in geographic or population-group HPSAs before implementation of the 
2002 provision, automatic designation as a facility HPSA resulted in no 
added benefit unless the HPSA score associated with the automatic 
designation was higher than the score for the geographic or population- 
group HPSA in which the facility was located. Although precise data 
were not available, HRSA officials estimated that many of the more than 
1,600 health centers--all of which received automatic designation as 
facility HPSAs--were located in geographic or population-group HPSAs 
before 2002. Of the more than 3,600 rural health clinics, 590 had 
certified they would treat everyone regardless of ability to pay and, 
as a result, received automatic HPSA designation as of September 2005; 
however, data were not available to determine how many of them were 
located in geographic or population-group HPSAs before receiving 
automatic HPSA designation. In addition, although officials that work 
with health centers and rural health clinics reported that these 
facilities in general welcomed the automatic HPSA designation because 
it could allow them the benefit of recruiting a physician through the 
NHSC, few had HPSA scores associated with the automatic designation 
that were high enough to qualify for a physician through the NHSC 
Scholarship Program. Specifically, as of September 2005, less than 5 
percent of the health centers and less than 1 percent of the rural 
health clinics with automatic facility HPSA designations had HPSA 
scores that were high enough to qualify for a physician through the 
NHSC Scholarship Program. However, all health centers and rural health 
clinics that received automatic designations as HPSAs, even those with 
lower HPSA scores, could apply in 2005 for a health care provider 
through another NHSC program, the NHSC Loan Repayment Program. 

We are recommending that HHS (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 demonstrating they still 
meet the designation criteria and (2) complete and publish HHS's 
proposal to revise the HPSA designation system and address the problems 
that have been identified in the current methodology for designating 
HPSAs. 

In commenting on a draft of this report, HHS concurred with our 
recommendations. Specifically, the department agreed that more timely 
publication of a list of designated HPSAs in the Federal Register is 
necessary, noting that publication in the Federal Register ensures that 
those HPSAs that have been proposed for withdrawal have their 
designations removed. The department also agreed with our 
recommendation to complete and publish its proposal to revise its HPSA 
designation system, stating that its proposal would address the various 
shortcomings that we have identified in this and previous reports. 

Background: 

Any agency or individual may request a HPSA designation for a 
geographic area, population group, or facility.[Footnote 11] According 
to HRSA officials, the vast majority of HPSA designation requests are 
submitted by state primary care offices.[Footnote 12] 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). 

Figure 1: HPSA Designation Request and Review Process, 2005: 

[See PDF for image] 

Source: GAO analysis of relevant statutes, regulations, and guidance. 

[A] Primary care associations are private, nonprofit organizations 
representing states or regions that provide training and technical 
assistance to facilities, including health centers, to help ensure that 
these facilities deliver high-quality primary care services in 
underserved communities. For more information, see HRSA, Bureau of 
Primary Health Care, "Directory of Primary Care Associations (PCA): 
April 2005," http://bphc.hrsa.gov/OSNP/PCADirectory.htm (downloaded 
Apr. 3, 2006). 

[End of figure] 

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).[Footnote 13] 

Figure 2: Types of HPSAs and Criteria Used to Designate Them, 2005: 

[See PDF for image] 

Source: GAO analysis of relevant statutes, regulations, and guidance. 

[A] HRSA defines a rational service area for the delivery of primary 
medical care services as (1) a county or group of contiguous counties 
whose population centers are within 30 minutes travel time of each 
other; (2) a portion of a county, or an area made up of portions of 
more than one county, whose population, because of topography, market 
or transportation patterns, distinctive population characteristics, or 
other factors has limited access to contiguous area resources, as 
measured generally by a travel time greater than 30 minutes to such 
resources; or (3) established neighborhoods and communities within 
metropolitan areas that display a strong self- identity (as indicated 
by a homogeneous socioeconomic or demographic structure or a tradition 
of interaction or interdependency), have limited interaction with 
contiguous areas, and that, in general, have a minimum population of 
20,000. 42 C.F.R. pt. 5, app. A, I B.1, II A.1.(a) (2005). 

[B] Special circumstances exist in an area if it has unusually high 
needs for primary care services or an insufficient supply of primary 
care providers. Unusually high needs may be demonstrated if, for 
example, more than 20 percent of the population have incomes below the 
federal poverty level. Insufficient supply of providers may be 
demonstrated if, for example, the area has unusually long waits for 
appointments for routine medical services and at least two-thirds of 
the area's physicians do not accept new patients. 42 C.F.R. pt. 5, app. 
A, I B.4., 5 (2005). 

[End of figure] 

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.[Footnote 
14] Health centers include consolidated health centers, health center 
look-alikes, and tribal health centers:[Footnote 15] 

² 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[Footnote 16] 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.[Footnote 17] 

² 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. 

² 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.[Footnote 18] 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.[Footnote 19] 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.[Footnote 20] 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.[Footnote 21] 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.[Footnote 22] Each year, it must also publish a 
list of designated HPSAs in the Federal Register.[Footnote 23] 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.[Footnote 24] 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.[Footnote 25] 

HPSAs Are Located in Every State and Are Used by Multiple Federal 
Programs: 

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. 

Number and Location of HPSAs: 

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). 

Table 1: Number of, Population in, and Physicians Needed in Geographic 
and Population-Group HPSAs, September 2005: 

HPSA type: Geographic area; 
Number of HPSAs: 1,646; 
Population in HPSAs[A]: 34,821,125; 
Primary care physicians needed[B]: 3,549. 

HPSA type: Population group; 
Number of HPSAs: 1,386; 
Population in HPSAs[A]: 24,912,956; 
Primary care physicians needed[B]: 3,392. 

HPSA type: Total; 
Number of HPSAs: 3,032; 
Population in HPSAs[A]: 59,734,081; 
Primary care physicians needed[B]: 6,941. 

Source: HRSA. 

[A] These numbers represent the resident civilian population of the 
related HPSA. For example, for geographic HPSAs that consist of an 
entire county, this number reflects the resident civilian population of 
the entire county. For population-group HPSAs, this number reflects 
that groups' population within particular geographic areas. 

[B] The number of additional full-time-equivalent primary care 
physicians required to achieve population-to-primary care physician 
ratios of 3,500:1 (less than 3,500:1 but greater than 3,000:1 under 
special circumstances), which are needed to remove the HPSA 
designations. 

[End of table] 

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.[Footnote 26] 

Figure 3: U.S. Counties with Geographic and Population-Group HPSAs, 
January 2006: 

[See PDF for image] 

Sources: GAO analysis of HRSA and U.S. Census Bureau data and 
MapInfo(map). 

Note: Counties that contained both geographic and population- group 
HPSAs are shown as geographic HPSAs. We identified 218 counties that 
included both geographic and population-group HPSAs as of January 2006. 

[End of figure] 

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,[Footnote 27] 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. 

Figure 4: Types of Facility HPSAs, September 2005: 

[See PDF for image] 

Source: GAO analysis of HRSA data. 

Note: Percentages of health center subtypes do not add to 63 percent 
because of rounding. 

[End of figure] 

As of September 2005, health centers with facility HPSA designations 
were located in all 50 states and the District of Columbia.[Footnote 
28] 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.[Footnote 29] 

Federal Programs Using HPSA Designations: 

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:[Footnote 
30] 

² 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.[Footnote 31] Scholarship recipients are limited to practicing 
at NHSC-approved practice sites in HPSAs with high need, as determined 
by the HPSA designation score.[Footnote 32] 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.[Footnote 33] 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.[Footnote 34] 

² 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.[Footnote 35] 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. 

² NHSC State Loan Repayment Program: NHSC provides grants to states to 
operate state loan repayment programs.[Footnote 36] 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. 

² 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.[Footnote 37] 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.[Footnote 38] For example: 

² CMS's Medicare Incentive Payment program pays physicians a 10 percent 
bonus for services provided to Medicare beneficiaries in a geographic 
HPSA.[Footnote 39] According to CMS's Office of Financial Management, 
the Medicare program paid about $148 million in these bonus payments in 
fiscal year 2005. 

² 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).[Footnote 40] 

² Federal agencies--including HHS, the Appalachian Regional 
Commission,[Footnote 41] and the Delta Regional Authority[Footnote 42]-
-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.[Footnote 43] 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.[Footnote 
44] 

² 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.[Footnote 45] 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.[Footnote 46] 

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."[Footnote 47] 

Research Points to Shortcomings with Designation Methodology: 

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.[Footnote 48] 

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.[Footnote 49] 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.[Footnote 50] 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.[Footnote 51] 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.[Footnote 
52] 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.[Footnote 53] 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.[Footnote 
54] 

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.[Footnote 55] 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.[Footnote 56] 

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.[Footnote 57] 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.[Footnote 58] 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.[Footnote 59] 
Meanwhile, those HPSAs that were proposed for withdrawal because they 
no longer meet the HPSA criteria have retained their HPSA 
designation.[Footnote 60] 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 HPSA Designation: 

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. 

Relatively Few Health Centers Had HPSA Scores High Enough to Obtain 
Providers through Certain Federal Programs: 

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.[Footnote 
61] 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. 

Figure 5: Distribution of HPSA Scores among Health Centers 
Automatically Designated as Facility HPSAs, September 2005: 

[See PDF for image] 

Source: GAO analysis of HRSA data. 

Notes: This figure includes scores for 1,624 of the 1,625 health 
centers that, as of September 2005, received a HPSA score as part of 
automatic designation as a facility HPSA. One tribal health center had 
not received a HPSA score from HRSA as of September 2005. Health 
centers that automatically received facility HPSA designation include 
those that received grants under the consolidated health center 
program, health center look-alikes, and tribal health centers. 

[A] For assignment of NHSC providers through the NHSC Scholarship 
Program for the period July 1, 2005, through June 30, 2006, a HPSA 
score of 14 or higher was required to be eligible for a physician; a 
score of 13 or higher was required for a nurse practitioner or 
physician assistant; and a score of 8 or higher was required for a 
nurse-midwife. HHS's J-1 visa waiver program required a HPSA score of 
14 or higher for all of 2005. 

[B] The maximum HPSA score a health center can receive is 25. 

[End of figure] 

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.[Footnote 62] 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. 

Few Rural Health Clinics Have Received Automatic HPSA Designation as 
Facility HPSAs: 

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.[Footnote 63] 

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).[Footnote 64] 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.[Footnote 65] 

Figure 6: Distribution of HPSA Scores among Rural Health Clinics 
Automatically Designated as Facility HPSAs, September 2005: 

[See PDF for image] 

Source: GAO analysis of HRSA data. 

Notes: This figure includes scores for 583 of the 590 rural health 
clinics that, as of September 2005, received a HPSA score as part of 
automatic designation as a facility HPSA. Seven rural health clinics 
that received the automatic HPSA designation had not received a HPSA 
score from HRSA as of September 2005. 

[A] For assignment of NHSC providers through the NHSC Scholarship 
Program for the period July 1, 2005, through June 30, 2006, a HPSA 
score of 14 or higher was required to be eligible for a physician; a 
score of 13 or higher was required for a nurse practitioner or 
physician assistant; and a score of 8 or higher was required for a 
nurse-midwife. HHS's J-1 visa waiver program required a HPSA score of 
14 or higher for all of 2005. 

[B] The maximum HPSA score a rural health clinic can receive is 25. 

[End of figure] 

Conclusions: 

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. 

Recommendations for Executive Action: 

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. 

Agency Comments: 

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 [Hyperlink, 
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. 

Signed by: 

Leslie G. Aronovitz: 
Director, Health Care: 

[End of section] 

Appendix I: Scoring of Health Professional Shortage Areas: 

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. 

Figure 7: Scoring of HPSAs, 2005: 

[See PDF for image] 

Source: HRSA. 

[A] For HPSA designation and scoring, HRSA counts nonfederal physicians 
who practice principally in one of the primary care specialties of 
general or family practice, general internal medicine, pediatrics, or 
obstetrics and gynecology. HRSA does not count federal physicians; 
physicians with NHSC or J-1 visa waiver obligations; or physicians 
engaged solely in administration, research, or teaching. See HRSA, 
Bureau of Health Professions, "Health Professional Shortage Area 
Guidelines for Primary Medical Care/Dental Designation," 
http://bhpr.hrsa.gov/shortage/hpsaguidepc.htm (downloaded Nov. 14, 
2005). 

[B] HHS's poverty guidelines for 2005 set the poverty level for a 
family of four at an annual income of $19,350 in the 48 contiguous 
states and the District of Columbia ($24,190 in Alaska and $22,260 in 
Hawaii). Poverty guidelines are not defined for American Samoa, the 
Commonwealth of the Northern Mariana Islands, the Federated States of 
Micronesia, Guam, Puerto Rico, the Republic of the Marshall Islands, 
the Republic of Palau, and the U.S. Virgin Islands; offices 
administering federal programs may decide whether to use the guidelines 
for the 48 contiguous states and the District of Columbia for those 
jurisdictions or some other procedure. 70 Fed. Reg. 8373-75 (Feb. 18, 
2005). 

[C] Infant mortality rate is defined as the number of infant deaths per 
1,000 live births. Low birth weight rate is defined as the percentage 
of live births below 2,500 grams (5 pounds, 8 ounces). 

[End of figure] 

[End of section] 

Appendix II: Medically Underserved Area or Population Designations and 
Medically Underserved Community Definition: 

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: 

² ratio of population to number of primary care physicians, 

² infant mortality rate, 

² percentage of the population with incomes below the federal poverty 
level, and: 

² 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.[Footnote 66] 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.[Footnote 67] 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.[Footnote 68] A medically underserved 
community is defined as an urban or rural area or population that: 

² is eligible for HPSA designation; 

² is eligible to be served by a community health center, migrant health 
center, or a grantee serving residents of public housing or the 
homeless; 

² 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: 

² is designated by a state governor (in consultation with the medical 
community) as a shortage area or medically underserved 
community.[Footnote 69] 

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.[Footnote 70] 

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.[Footnote 71] 
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. 

[End of section] 

Appendix III: Scope and Methodology: 

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.[Footnote 72] 

* 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.[Footnote 73] 

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.[Footnote 74] 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.[Footnote 75] 

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:[Footnote 76] 

² ratio of population to primary care physicians, 

² indicators of the population with incomes below the poverty level 
(poverty or income), 

² infant mortality rate, 

² distance to health care services, and: 

² 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.[Footnote 77] 
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: 

² 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.[Footnote 78] 

² 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. 

[End of section] 

Appendix IV: Federal Programs Using Health Professional Shortage Area 
and Other Designations of Underservice: 

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). 

Table 2: Programs and Administering Agencies That Used HPSA, MUA, MUP 
or Other Designations to Allocate Resources or Provide Benefits in 
Fiscal Year 2005: 

Program: Consolidated health center program; 
Agency administering program or benefit: HRSA and CMS; 
Resource allocated or benefit provided: Awards grants for operation of 
health centers and other activities; provides benefits associated with 
federally qualified health center status, including eligibility to 
participate in a drug discount program and to receive reimbursement 
from Medicare and Medicaid using special payment mechanisms, which 
serve as an incentive for becoming a health center; 
Federal funding information[A]: $1,734 million (funding from FY 2005 
appropriations for HRSA)[B]; 
Designation(s) used by program: MUA; MUP. 

Program: Federally qualified health center look-alike program; 
Agency administering program or benefit: HRSA and CMS; 
Resource allocated or benefit provided: Provides benefits associated 
with federally qualified health center status, including eligibility to 
participate in a drug discount program and to receive reimbursement 
from Medicare and Medicaid using special payment mechanisms, which 
serve as an incentive for becoming a health center; 
Federal funding information[A]: [B]; 
Designation(s) used by program: MUA; MUP. 

Program: Indian Health Scholarship Program; 
Agency administering program or benefit: IHS; 
Resource allocated or benefit provided: Awards American Indian and 
Alaska Native students with scholarships for service in certain 
practices in HPSAs or other practice locations authorized by 
statute.[C]; 
Federal funding information[A]: $9 million (funding from FY 2005 
appropriations for IHS); 
Designation(s) used by program: HPSA[C]. 

Program: J-1 visa waivers for physicians at the request of federal 
agencies (3 programs); 
Agency administering program or benefit: Department of Homeland 
Security's U.S. Citizenship and Immigration Services (USCIS), 
Department of State, Appalachian Regional Commission, Delta Regional 
Authority, HHS's Office of Global Health Affairs, and HRSA[D]; 
Resource allocated or benefit provided: Waives requirement for certain 
foreign physicians to return to their home country or country of last 
legal residence for 2 years after graduate medical education at the 
request of an interested federal agency in exchange for at least 3 
years of service in an area designated by the Secretary of Health and 
Human Services as having a shortage of health professionals; 
Federal funding information[A]: Not applicable; 
Designation(s) used by program: HPSA[E]; MUA; MUP. 

Program: J-1 visa waivers for physicians at the request of state health 
departments (also known as the Conrad Program); 
Agency administering program or benefit: USCIS, Department of State, 
state health departments[D]; 
Resource allocated or benefit provided: Waives requirement for certain 
foreign physicians to return to their home country or country of last 
legal residence for 2 years after graduate medical education in 
exchange for at least 3 years of service in an area designated by the 
Secretary of Health and Human Services as having a shortage of health 
professionals. Limited to 30 waivers per state per year. Up to five 
waivers may be for physicians to practice outside of shortage areas as 
long as they practice in a facility that serves patients residing in 
such areas; 
Federal funding information[A]: Not applicable; 
Designation(s) used by program: HPSA:[F]Practice in a HPSA  or treating 
the residents of HPSAs; MUA: Practice in an MUA or treating the 
residents of MUAs; MUP: Practice in an MUP or treating the residents of 
MUPs. 

Program: Medicare Incentive Payment program; 
Agency administering program or benefit: CMS; 
Resource allocated or benefit provided: Provides 10 percent bonus 
payment on Medicare payments for physician services in geographic 
HPSAs; 
Federal funding information[A]: $148 million (FY 2005 Medicare 
expenditures); 
Designation(s) used by program: HPSA: Geographic HPSAs only. 

Program: National Health Service Corps (4 programs)[G]; 
Agency administering program or benefit: HRSA; 
Resource allocated or benefit provided: Awards scholarships to or 
provides money to repay educational loans of students and health 
professionals in exchange for at least 2 years of service in a HPSA; 
supports commissioned officers of the U.S. Public Health Service to 
serve for 3 years in the neediest HPSAs; 
Federal funding information[A]: $131 million (funding from FY 2005 
appropriations for HRSA); 
Designation(s) used by program: HPSA. 

Program: National Interest Waivers for Immigrant Physicians; 
Agency administering program or benefit: USCIS; 
Resource allocated or benefit provided: Waives the job offer 
requirement placed on certain immigrants, including physicians who 
agree to practice in a HPSA, an MUA, an MUP, or at Department of 
Veterans Affairs facilities.[H]; 
Federal funding information[A]: Not applicable; 
Designation(s) used by program: HPSA: Geographic HPSAs only; MUA. 

Program: Rural Health Clinic program; 
Agency administering program or benefit: CMS; 
Resource allocated or benefit provided: Provides special Medicare and 
Medicaid payment mechanisms for rural health clinics, which serve as an 
incentive for becoming a rural health clinic; 
Federal funding information[A]: $413 million (2004 Medicare 
expenditures);[I] $333 Million (FY 2004 Medicaid expenditures)[I]; 
Designation(s) used by program: HPSA: Rural geographic and population- 
group HPSAs only; MUA: Rural MUAs only; Other: Rural areas designated 
by a state's governor as shortage areas. 

Program: Scholarships for Disadvantaged Students Program; 
Agency administering program or benefit: HRSA; 
Resource allocated or benefit provided: Awards grants to health 
professions schools to provide scholarships to full-time, financially 
needy students from disadvantaged backgrounds enrolled in eligible 
health professions or nursing programs. Funding priority is given to 
schools applying for the funding based on the proportion of graduating 
students going into primary care, the proportion of underrepresented 
minority students, and the proportion of graduates working in medically 
underserved communities.[J, K]; 
Federal funding information[A]: $47 million (funding from FY 2005 
appropriations for HRSA); 
Designation(s) used by program: HPSA; MUA; MUP; Other: Other medically 
underserved communities[K]. 

Program: Title VII health professions education and training grant 
programs[L] (16 programs); 
Agency administering program or benefit: HRSA; 
Resource allocated or benefit provided: Provides grants for health 
professions education and training programs. Funding preference is 
given to applicants that (1) place a high or increasing number of 
graduates or program completers in settings having the principal focus 
of serving medically underserved communities or (2) have 25 percent or 
more of their graduates in full-time practice settings in medically 
underserved communities and meet other statutory requirements.[K, M]; 
Federal funding information[A]: $165 million (funding from FY 2005 
appropriations for HRSA); 
Designation(s) used by program: HPSA; MUA; MUP; Other: Other medically 
underserved communities[K]. 

Program: Title VIII nursing education programs[N] (2 Programs); 
Agency administering program or benefit: HRSA; 
Resource allocated or benefit provided: Provides grants to institutions 
to provide financial support through traineeships for registered nurses 
enrolled in advanced education nursing programs or in a master's degree 
nurse anesthesia program. In awarding grants, a funding preference is 
given to applicants whose projects will substantially benefit rural or 
underserved populations, using sites identified under the definition of 
medically underserved community as proxies, and gives special 
consideration for applicants with students who have committed to 
practicing in HPSAs after graduation.[K, O]; 
Federal funding information[A]: $17 million (funding from FY 2005 
appropriations for HRSA); 
Designation(s) used by program: HPSA; MUA; MUP; Other: Other medically 
underserved communities[K]. 

Source: GAO analysis of HHS and other federal and state agency 
information. 

Note: In addition to the programs included in the table, other 
programs, including rural health grant programs administered by HRSA, 
have used the HPSA designation to some degree in allocating resources. 
For example, in fiscal year 2005, HRSA's announcement for rural health 
network development grants stated that a funding preference would be 
given to those qualified applicants where the service area was located 
in a designated HPSA, was a medically underserved community, or served 
medically underserved populations. HRSA does not maintain a list of all 
programs using the HPSA designation to allocate resources or provide 
benefits. 

[A] Funding amounts from HRSA and IHS reflect fiscal year 2005 
appropriations or budget authority as reported in the agencies' fiscal 
year 2006 budget justifications and provided by agency officials. 
Budget authority is the authority provided by federal law to enter into 
financial obligations that will result in future outlays involving 
federal government funds. Budget authority includes appropriations and 
also includes the authority to borrow, enter into contracts, or to 
obligate and expend offsetting receipts and collections. Funding 
amounts from CMS reflect expenditure amounts under the Medicare and 
Medicaid programs from data in reports provided by CMS officials. 

[B] According to CMS officials, although data on Medicare and Medicaid 
payments to federally qualified health centers are available, data on 
expenditures for specific types of health centers, such as consolidated 
health centers or federally qualified health center look-alikes, are 
not available. Data from reports provided by CMS officials show that in 
2004, the most recent year for which complete data were available, 
Medicare payments to federally qualified health centers totaled about 
$278 million; in fiscal year 2004, the most recent year for which data 
were available, Medicaid payments to federally qualified health centers 
totaled about $778 million. 

[C] Scholarship recipients must fulfill a service requirement by, for 
example, being engaged in full-time private practice in a HPSA 
addressing the health care needs of a substantial number of Indians. 
Other types of service opportunities are also available for scholarship 
recipients. 

[D] A federal agency or state (including the District of Columbia, 
Guam, Puerto Rico, and the U.S. Virgin Islands) can request J-1 visa 
waivers for physicians who entered the United States for graduate 
medical education under the Department of State's exchange visitor 
program. After being recommended by the Department of State, waivers 
are granted by USCIS. Three federal agencies--HHS, Appalachian Regional 
Commission, and Delta Regional Authority--requested waivers for 
physicians to practice in underserved areas in fiscal year 2005. Also 
in fiscal year 2005, all 50 states, the District of Columbia, and Guam 
requested J-1 visa waivers for physicians to practice in facilities 
located in or treating residents of underserved areas under a provision 
of the Immigration and Nationality Act, also known as the Conrad 
Program. 

[E] The Appalachian Regional Commission's and HHS's J-1 visa waiver 
programs require waiver physicians to practice in HPSAs. The Delta 
Regional Authority's J-1 visa waiver program requires waiver physicians 
to practice in HPSAs, MUAs or MUPs. 

[F] Individual state requirements may vary. For example, one state may 
require J-1 visa waiver physicians to practice in HPSAs, while other 
states may require them to practice in HPSAs, MUAs, or MUPs. 

[G] National Health Service Corps programs include the Scholarship 
Program, federal Loan Repayment Program, State Loan Repayment Program, 
and Ready Responders. 

[H] 8 U.S.C. § 1153(b)(2)(B)(ii), 8 C.F.R. § 204.12 (2006). 

[I] According to CMS officials, the most recent completed year for 
which data on rural health clinics were available was 2004 for Medicare 
payments and fiscal year 2004 for Medicaid payments. 

[J] Funding priorities are factors that provide a grant applicant with 
a fixed amount of additional rating points, which could place the 
applicant in a more favorable position to receive a grant award than 
the applicant would be without the additional rating points. 

[K] A medically underserved community is an urban or rural area or 
population that (1) is eligible for HPSA designation; (2) is eligible 
to be served by a community health center, migrant health center, or a 
grantee serving residents of public housing or the homeless; (3) has a 
shortage of personal health services, as determined under criteria 
issued by the Secretary of Health and Human Services relating to rural 
health clinics; or (4) is designated by a state governor (in 
consultation with the medical community) as a shortage area or 
medically underserved community. 

[L] Includes 15 health professions education programs authorized under 
title VII of the Public Health Service Act that have a funding 
preference for applicants that place a high or increasing number of 
graduates or those completing the program in settings having the 
principal focus of serving medically underserved communities, including 
(1) programs for training in family medicine, general internal 
medicine, general pediatrics, physician assistants, general dentistry, 
or pediatric dentistry; (2) programs for area health education centers; 
(3) Health Education and Training Centers program; (4) Quentin N. 
Burdick Program for Rural Interdisciplinary Training; (5) programs for 
allied health projects and other disciplines; and (6) geriatric 
education programs. In addition to these 15 programs, 1 additional 
grant program authorized under title VII of the Public Health Service 
Act, Health Administration Traineeships and Special Projects, has a 
funding preference for applicants that have not less than 25 percent of 
their graduates in full-time practice settings in medically underserved 
communities, that recruit and admit students from medically underserved 
communities, that have established relationships with public and 
nonprofit providers of health care in the community involved, and that 
emphasize employment with public and nonprofit entities in their 
training of students. 

[M] A funding preference is also available to applicants implementing 
new programs if they meet at least four of seven statutory criteria. 

[N] Includes the Advanced Education Nursing Traineeship Program and 
Nurse Anesthetist Traineeship Program. 

[O] The funding preference also applies to applicants that will help 
meet public health nursing needs in state or local health departments. 
Special considerations are factors considered in making funding 
decisions that are not review criteria, preferences, or priorities, for 
example, ensuring that there is an equitable geographic distribution of 
grant recipients. 

[End of table] 

[End of section] 

Appendix V: Comments from the Department of Health and Human Services: 

Office of the Assistant Secretary for Legislation:  
Department Of Health & Human Services:  
Washington, D.C. 20201: 

SEP 19 2006: 

Leslie G. Aronovitz: 
Director, Health Care: 
U.S. Government Accountability Office: 
Washington, DC 20548: 

Dear Ms. Aronovitz: 

Enclosed are the Department's comments on the U.S. Government 
Accountability Office's (GAO) draft report entitled, "Health 
Professional Shortage Areas: Problems Remain with Shortage Area 
Designation System" (GAO-06-548), before its publication. These 
comments represent the tentative position of the Department of Health 
and Human Services and are subject to reevaluation when the final 
version of this report is received. 

The Department provided several technical comments directly to your 
staff. 

The Department appreciates the opportunity to comment on this draft 
report before its publication. 

Sincerely, 

Signed by: 

Vincent J. Ventimiglia, Jr. 
Assistant Secretary for Legislation: 

Comments Of The Department Of Health And Human Services On The U.S. 
Government Accountability Office's (GAO) Draft Report "Health 
Professional Shortage Areas: Problems Remain With Shortage Area 
Designation System" GAO-0b-548: 

General Comments: 

The Department concurs with the two major recommendations, and is 
pleased to report progress on both items. The Department has developed 
a new methodology to address many of the issues raised in this report. 
There are, however, some areas it the report that should be modified to 
more accurately reflect the impact of the automatic designation process 
and has provided some additional data for consideration in these areas. 

The Department agrees with the Government Accountability Office (GAQ 
that a more timely publication of the Federal Register listing is 
necessary to assure that only those areas that meet the regulations 
remain fully designated. Together, the Federal Register and HRSA on- 
line data bases, accessible by the general public, serve as 
notification of designated Health Professional Shortage Areas (HPSAs) 
to all interested parties. Additionally, the Department informs 
interested parties of new, continued, revised, or proposed for 
withdrawal designations by way of a formal letter which states the 
effective date of the action However, the Department is proposing a 
change in the process of withdrawing Health Professional Shortage Areas 
(HPSAs). 

The Department agrees with the GAO that the current methodologies for 
identifying areas and populations need to be revised to reflect the 
current health care environment. In addition to the primary care 
proposal referenced in this report, the Department is near completion 
of a revised methodology for designating dental shortage areas. The 
Department has also made significant progress in developing a revised 
methodology for mental and behavioral health. Finally, the Department 
is also near completion of the design of a totally new designation 
process for identifying areas and facilities experiencing a shortage of 
nurses. In the next 2 to 3 years, the Department hopes to have all of 
these new designation methodologies completed and implemented. The 
Department's goal is to designate shortage areas to facilitate access 
to primary health care services for the people without such services. 
The Department is always appreciative of suggestions to improve our 
designation process, as we strive for excellence in service. 

Impact of Automatic HPSA Designation for Federally Qualified Health 
Centers and Selected Rural Health Clinics: 

It is the Department's opinion that the report as currently drafted 
gives a somewhat misleading assessment of the impact of the automatic 
designation process, Since an estimated 50 percent or more of the 
health centers were already in HPSAs, they would not be expected to be 
helped by this provision. A slight rewording of the document in places 
noted in the attachment would provide a more accurate assessment of the 
process. 

In the 2005 placement cycle of the National Health Service Corps 
(NHSC), there were, in fact, 216 placements made to health centers as a 
result of their automatic HPSA status. Of these, 6 were scholars, 209 
were loan repayers, and 1 was a Ready Responder. At this point in the 
2006 placement cycle, 108 placements have been completed or are pending 
at health centers with automatic HPSAs. In 2005, approximately 16 
percent of new NHSC placements were made to sites with a HPSA score of 
"0." These are sites that clearly benefited from the new provision in 
the designation process. Also, most State Loan Repayment programs do 
not have scoring limits, so it is likely that some of these clinicians 
were placed in health centers that are now eligible based on their 
automatic status; 85 percent of the State Loan Repayment clinicians 
serve in health centers. 

In addition, it should be acknowledged that the Health Resources and 
Services Administration (HRSA) took several steps to inform the health 
centers and interested parties about the automatic scoring process and 
how they could improve their scores if they wished. The scoring was 
performed per established regulations to determine the greatest 
shortage; in the absence of data being submitted, national data sources 
were used. Information was posted on the HPSA Web site in the first 
year after t he scores were developed in 2003 to provide alternative 
data sources and options. The same information was shared with other 
interested parties, including the Primary Care Offices (PCOs), which 
are located in the State Health Departments. A number of sites took 
advantage of this information and submitted additional data that 
justified an increased score. In several cases, the backup data were 
shared with the PCOs to explain the source of the current scores and 
where alternative data could be applied. 

Moreover, it should be recognized that the total number of HPSA sites 
which can qualify to receive NHSC Scholars in any particular year is 
limited by statute to no more than twice the number of scholars 
available. The HPSA scoring process is designed to allow comparison of 
relative need among sites, so that sites of greatest need will he 
included on each year's list. It is not surprising that HPSA sites in 
areas meeting the objective HPSA criteria typically score higher than 
other facilities automatically designated. 

It is also important to recognize that having a higher score and 
obtaining a place on the scholarship list is no guarantee of getting a 
clinician through the NHSC or the Health and Human Services (HHS) J-1 
Visa Waiver program. Every year there are health centers on the 
recruitment list that do not succeed in recruiting a clinician from the 
scholarship program. Increasing the number of sites with higher scores 
will increase the competition among health centers for an already 
scarce resource, so a singular focus on the scores perhaps provides a 
false sense of security for sites which feel that is the only obstacle 
to successful recruiting. 

Finally, in terms of the HHS J-1 Visa Waiver program, it is important 
to recognize that this program has decreased dramatically with the 
increase in the Conrad 3) programs at the State level. Therefore, the 
fact that there was initially a higher score inquired for eligibility 
for the Federal program had a very limited effect on the recruitment of 
J-1 Visa physicians, most of whom are now going through the State 
programs. In f act, in 2005 only 4 J-1 Visa Waivers were approved 
through the HHS program, while approximately 900 were placed through 
the State Conrad programs, most of which did not have a score limit. 

GAO Recommendation: 

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 the their designation. 

HHS Response: 

The Department also concurs with GAO's recommendation that HRSA should 
resume publishing lists of HPSA designations, or at least lists of HPSA 
withdrawals in the Federal Register, to ensure that designations which 
have already been proposed for withdrawal (by letter from the Bureau of 
Health Profession's Shortage Designation Branch) actually get 
withdrawn. 

GAO Recommendation: 

Complete and publish its proposal to revise the HPSA designation system 
and address the shortcomings that have been identified in the current 
methodology for designating HPSAs. 

HHS Response: 

The Department concurs with this recommendation that HRSA's already- 
developed proposal to revise the regulations governing primary care 
HPSA and Medically Underserved Area/Population (MUA/P) designations, in 
the works since u 1998 Notice of Proposed Rule Making was withdrawn, 
should be implemented as soon as possible. This would address the 
various shortcomings of the existing criteria and process that GAO has 
identified in this and previous reports. 

HHS Overall Comment: 

It should be clearly stated that this report covers only the primary 
care designation process, and does not include the dental or mental 
health processes. References to the scores and factors throughout the 
report would be slightly different if all three disciplines were 
included. 


[End of section] 

Appendix VI: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Leslie G. Aronovitz, (312) 220-7600 or aronovitzl@gao.gov: 

Acknowledgments: 

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. 

[End of section] 

Related GAO Products: 

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. 

[End of section] 

(290486): 

FOOTNOTES 

[1] Throughout this report, we use the term HPSA to denote health 
professional shortage areas for primary care, which HHS considers to 
include medical specialties of general or family practice, general 
internal medicine, pediatrics, and obstetrics and gynecology. In 
addition to primary care HPSAs, HHS designates HPSAs for fields other 
than primary care, including dental and mental health. 

[2] HPSAs can be located in all states and the District of Columbia, as 
well as in American Samoa, the Commonwealth of the Northern Mariana 
Islands, the Federated States of Micronesia, Guam, Puerto Rico, the 
Republic of the Marshall Islands, the Republic of Palau, and the U.S. 
Virgin Islands. 

[3] Federally qualified health centers, referred to as health centers 
in this report, include (1) health centers that receive a grant or 
funding from a grant under the consolidated health center program 
authorized under section 330 of the Public Health Service Act; (2) 
facilities, called look-alikes, that are determined by the Secretary of 
Health and Human Services to meet the requirements for receiving such a 
grant; and (3) outpatient health programs or facilities operated by a 
tribe or tribal organization under the Indian Self-Determination Act or 
by an urban Indian organization receiving funds under title V of the 
Indian Health Care Improvement Act. Health centers are located in both 
urban and rural areas and are required to treat everyone regardless of 
ability to pay. According to data from HHS's Health Resources and 
Services Administration (HRSA), the agency that administers the 
consolidated health center program and certifies look-alikes, there 
were over 1,600 health centers as of September 2005. 

[4] Rural health clinics are located in rural areas and, unlike health 
centers, are not required to provide services to all individuals, 
regardless of their ability to pay. According to data from HHS's 
Centers for Medicare & Medicaid Services (CMS), the agency that 
certifies these clinics as rural health clinics for purposes of the 
Medicare and Medicaid programs, there were over 3,600 rural health 
clinics as of September 2005. 

[5] In addition to the ratio of population to primary care physicians, 
HPSA designation is based on other factors, such as health care 
resources available in neighboring areas. For those geographic HPSAs 
that have their HPSA designations on the basis of having unusually high 
needs for primary care services, the HPSA designations are also based 
on at least one of three other factors: the area's infant mortality 
rate, the percentage of the population with incomes below the poverty 
level, or the area's birth rate. See HRSA, Bureau of Health 
Professions, "Health Professional Shortage Area Primary Medical Care 
Designation Criteria," http://bhpr.hrsa.gov/shortage/hpsacritpcm.htm 
(downloaded May 15, 2006). HRSA also automatically designates health 
centers and certain rural health clinics as facility HPSAs; these 
facilities are not required to meet a ratio of population to primary 
care physicians for HPSA designation. 

[6] Four factors, including factors used for HPSA designation, 
determine a HPSA's score--ratio of population to primary care 
physicians, percentage of the population with incomes below the poverty 
level, infant mortality rate or low birth weight rate, and time or 
distance to the nearest source of primary care. Each HPSA is scored on 
a scale of 0 to 25, with higher scores indicating greater relative need 
for primary care providers. See appendix I for additional information 
on HPSA scoring. 

[7] Since 1995 we have reported on shortcomings of the HPSA designation 
system. See GAO, Health Care Shortage Areas: Designations Not a Useful 
Tool for Directing Resources to the Underserved, GAO/HEHS-95-200 
(Washington, D.C.: Sept. 8, 1995), as well as "Related GAO Products" at 
the end of this report. 

[8] 63 Fed. Reg. 46538-55 (Sept. 1, 1998). The proposal included 
provisions to combine the HPSA designation system with HRSA's other 
designations of underservice: the medically underserved area (MUA) and 
medically underserved population (MUP) designations. See appendix II 
for more information on the MUA and MUP designations. 

[9] Pub. L. No. 107-251, § 302(a)(1)(A), (e); 116 Stat. 1621, 1643- 
1645. Under this act, health centers and those rural health clinics 
certifying that they serve all individuals, regardless of ability to 
pay, automatically receive designation as facility HPSAs. 

[10] See appendix III for additional information on our scope and 
methodology. 

[11] HPSA designations may be requested for geographic areas, 
population groups, and facilities located in all states and the 
District of Columbia, as well as in American Samoa, the Commonwealth of 
the Northern Mariana Islands, the Federated States of Micronesia, Guam, 
Puerto Rico, the Republic of the Marshall Islands, the Republic of 
Palau, and the U.S. Virgin Islands. The HPSA request and review process 
is the same for all locations. 

[12] State primary care offices work toward addressing the needs of the 
medically underserved in their states and receive funding through HRSA 
grants and cooperative agreements. For more information, see HRSA, 
Bureau of Primary Health Care, "Directory of Primary Care Offices 
(PCO): December 2005," http://bphc.hrsa.gov/OSNP/PCODirectory.htm 
(downloaded June 19, 2006). 

[13] See 42 C.F.R. pt. 5, apps. A-G (2005). 

[14] 42 U.S.C. §§ 254e(a)(1), 254g(a)(1), 1395x(aa)(2), (4). 

[15] Health centers are reimbursed under CMS's Medicare and Medicaid 
programs using special payment mechanisms that serve as an incentive 
for becoming a health center. See also GAO, 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). 

[16] Some health centers receive grant funding from another entity that 
is the recipient of such a grant. To be considered a health center, 
they must also be eligible to receive a grant directly. 

[17] A consolidated health center must serve an area or population 
designated by HHS as an MUA or MUP. See appendix II for information on 
the MUA and MUP designations. 

[18] Rural health clinics are reimbursed under CMS's Medicare and 
Medicaid programs using special payment mechanisms that serve as an 
incentive for becoming a rural health clinic. To be reimbursed under 
Medicare and Medicaid, 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 an MUA. See appendix 
II for additional information on the MUA designation. 

[19] See appendix I for additional information on the scoring of HPSAs. 

[20] A Primary Care Service Area is a zip code with one or more primary 
care providers or any contiguous zip codes whose Medicare populations 
seek the largest share of their primary care from those providers. For 
more information, see Center for Evaluative Clinical Sciences at 
Dartmouth, "The Primary Care Service Area Project," 
http://www.dartmouth.edu/~cecs/pcsa/pcsa.html# (downloaded Jan. 31, 
2006). 

[21] In addition, health centers that provide services at more than one 
delivery site receive a HPSA score for the entire entity, which is 
calculated by averaging the individual HPSA scores assigned to each 
site. If any individual site of a health center is in a geographic or 
population-group HPSA or has been designated as a facility HPSA through 
the standard request and review process, the site may use that HPSA's 
score for purposes of applying for federal programs. 

[22] 42 U.S.C. § 254e(d)(1); 42 C.F.R. § 5.4(b) (2005). 

[23] 42 U.S.C. § 254e(d)(2). 

[24] 42 C.F.R. § 5.4(d) (2005). 

[25] 42 U.S.C. § 254e(a)(1). 

[26] Geographic HPSAs were also located in American Samoa, the 
Commonwealth of the Northern Mariana Islands, the Federated States of 
Micronesia, Guam, Puerto Rico, the Republic of the Marshall Islands, 
and the Republic of Palau. Population-group HPSAs were also located in 
Puerto Rico and the U.S. Virgin Islands. 

[27] Of the 1,625 health centers that were automatically designated as 
facility HPSAs as of September 2005, we estimated 989 were grantees 
under HHS's consolidated health center program. (Consolidated health 
center program grantees may provide services at more than one delivery 
site, and although data were not available on the number of these 
delivery sites, a HRSA official estimated that consolidated health 
center program grantees operated more than 3,700 service delivery sites 
in 2005.) In addition, we estimated 99 health center look-alikes and 
537 tribal health centers were automatically designated as facility 
HPSAs as of September 2005. 

[28] Health centers with facility HPSA designations were also located 
in American Samoa, Guam, Puerto Rico, the Republic of the Marshall 
Islands, the Republic of Palau, and the U.S. Virgin Islands. 

[29] As of September 2005, rural health clinics with facility HPSA 
designations were located in all states except the following: Alaska, 
Arizona, Connecticut, Delaware, Hawaii, Massachusetts, Maryland, New 
Jersey, and Rhode Island, as well as the District of Columbia. Federal 
or state correctional institutions with facility HPSA designations were 
located in all states except Alaska, Delaware, North Dakota, and New 
Mexico, as well as the District of Columbia. A federal or state 
correctional institution with a facility HPSA designation was also 
located in Puerto Rico. 

[30] A fifth NHSC program--the Community Scholarship Program--did not 
award any new scholarships in fiscal year 2005, and therefore we 
excluded this program from our analysis. 

[31] 42 U.S.C. § 254l(f)(1)(B)(v). Scholarship recipients receive 
payment of tuition and other educational expenses, such as fees and 
books, as well as a stipend for up to 4 years of education. For each 
year of support received, the recipient is required to serve 1 year in 
an NHSC-approved practice site in a high-need HPSA, with a minimum 
service commitment of 2 years. 

[32] NHSC providers must practice in NHSC-approved practice sites that 
agree to use a sliding fee schedule or other method to reduce fees to 
ensure that no financial barriers to care exist. 

[33] 70 Fed. Reg. 51356-7 (Aug. 30, 2005). The minimum HPSA score for 
the practice sites eligible for NHSC scholarship recipients in a given 
year depends on both the practice sites applying for scholarship 
recipients in that discipline and the number of scholarship recipients 
graduating in each discipline that year. 

[34] In this report, the numbers of NHSC providers represent those 
primary care providers practicing in HPSAs to fulfill their service 
obligation at the end of fiscal year 2005; they do not include about 
550 NHSC dental providers and about 920 NHSC mental health providers 
practicing in HPSAs designated for dental or mental health. The numbers 
also exclude 13 NHSC loan repayment recipients who were chiropractors 
or pharmacists practicing in HPSAs to fulfill their NHSC service 
obligation under a demonstration project authorized by the Public 
Health Service Act. See 42 U.S.C. § 254t. 

[35] 42 U.S.C. § 254l-1(f), (g). For the 2-year minimum service 
commitment, NHSC will pay up to $50,000, based on the loan repayment 
recipient's qualifying educational loans, with the potential to 
participate in the program for additional years, one year at a time, 
with NHSC paying up to $35,000 per year. See HRSA, Bureau of Health 
Professions, National Health Service Corps, "Loan Repayment Program," 
http://nhsc.bhpr.hrsa.gov/join_us/lrp.asp (downloaded May 13, 2006). 

[36] 42 U.S.C. § 254q-1. States must provide matching funds to be 
eligible for a grant. 

[37] 69 Fed. Reg.70459 (Dec. 6, 2004). Applicants for the Ready 
Responders must file a U.S. Public Health Service Commissioned Corps 
application and meet the requirements for such commissioning. Initial 
assignments will last up to 3 years, after which providers choosing to 
stay in the U.S. Public Health Service move on to new assignments. 

[38] See appendix IV for a list of programs using the HPSA designation 
and HRSA's other designations of underservice (MUA and MUP) to allocate 
resources or provide benefits in fiscal year 2005. 

[39] 42 U.S.C. § 1395l(m). 

[40] See appendix II for additional information on the MUA designation. 

[41] The Appalachian Regional Commission is a federal-state economic 
development partnership between the federal government and 13 states. 
The commission initiates economic and community development programs 
and serves as an advocate for the people in the Appalachian Region, 
including all of West Virginia and parts of 12 other states: Alabama, 
Georgia, Kentucky, Maryland, Mississippi, New York, North Carolina, 
Ohio, Pennsylvania, South Carolina, Tennessee, and Virginia. 

[42] The Delta Regional Authority is a federal-state partnership 
between the federal government and eight states. The authority was 
created to remedy severe and chronic economic distress by stimulating 
economic development and fostering partnerships that will have a 
positive impact on the economy of the region. The authority covers 240 
counties and parishes in Alabama, Arkansas, Illinois, Kentucky, 
Louisiana, Mississippi, Missouri, and Tennessee. 

[43] Foreign physicians may enter the United States for graduate 
medical education as participants under an exchange visitor program 
administered by the Department of State. These physicians enter the 
United States with J-1 visas and are required to return to their home 
country or country of last legal residence for at least 2 years when 
they complete their graduate medical education. They may, however, 
obtain a waiver of this requirement from the Department of Homeland 
Security's U.S. Citizenship and Immigration Services (USCIS) at the 
request of a state or federal agency, if the physician has agreed to 
practice in or work at a facility that treats residents of a geographic 
area or areas designated by the Secretary of Heath and Human Services 
as having a shortage of health care professionals, such as a HPSA, for 
3 years. 8 U.S.C. § 1184(l)(1)(D). In May 2006, we testified that, in 
fiscal year 2005, states and federal agencies requested more than 1,000 
waivers for physicians--including those practicing primary care 
specialties and those practicing nonprimary care specialties--to work 
in facilities that are located in, or treat residents of, HPSAs or 
other underserved areas. More than 90 percent of these were states' 
waiver requests; less than 10 percent were federal agencies' requests. 
See GAO, 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). 

[44] Effective April 3, 2006, HHS revised its J-1 visa waiver policy. 
Rather than require foreign physicians to practice in HPSAs with a 
score of 14 or higher, the revised policy requires foreign physicians 
seeking a waiver to practice in HPSAs with a score of 7 or higher in 
order for HHS to request a J-1 visa waiver through its program. See 
HHS, "Applications for Waiver of the Two-year Foreign Residence 
Requirement (Clinical Care) of the Exchange Visitor Program," 
http://www.globalhealth.gov/newguidelines1.shtml (downloaded Mar. 17, 
2006). 

[45] See 42 U.S.C. §§ 295d(c), 295j. Funding preferences are factors 
that place a grant application ahead of others without a preference on 
a list of applicants recommended for funding by a review committee. 

[46] 42 U.S.C. § 295p(6)(A), (B). 

[47] Council on Graduate Medical Education, Department of Health and 
Human Services, Health Resources and Services Administration, Tenth 
Report: Physician Distribution and Health Care Challenges in Rural and 
Inner-City Areas (Rockville, Md.: February 1998). 

[48] Kevin Grumbach et al., "Physician Supply and Access to Care in 
Urban Communities," Health Affairs, vol. 16, no. 1 (1997). For this 
report, researchers analyzed data from a 1993 survey of a sample of 
California residents from 41 urban communities based on guidelines for 
defining primary care service areas developed by state agencies. 
Researchers examined the relationship between income of the respondents 
and the number of physicians per 100,000 population in those areas, 
using data from the 1994 American Medical Association Physician 
Masterfile for physicians in medical specialties of general or family 
practice, general internal medicine, pediatrics, and obstetrics and 
gynecology. 

[49] See, for example, Council on Graduate Medical Education, 
Department of Health and Human Services, Health Resources and Services 
Administration, Tenth Report: Physician Distribution and Health Care 
Challenges in Rural and Inner-City Areas, and Donald H. Taylor Jr. and 
Thomas C. Ricketts, "Examining Alternative Measures of Medical 
Underservice for Rural Areas: Executive Summary" (Working Paper No. 39, 
North Carolina Rural Health Research Program, Cecil G. Sheps Center for 
Health Services Research, University of North Carolina at Chapel Hill, 
August 1995). 

[50] See GAO/HEHS-95-200. 

[51] This estimate was derived by subtracting the total number of 
primary care providers practicing in HPSAs from the total number 
reported as needed by the HPSA system. See GAO/HEHS-95-200. 

[52] Not all HPSAs rely on county-level data. For example, in September 
2005, although 831 geographic HPSAs were entire counties, 815 
geographic HPSAs were portions of counties, such as census tracts. 

[53] See John Robst and Glenn G. Graham, "The Relationship between the 
Supply of Primary Care Physicians and Measures of Heath," Eastern 
Economic Journal, vol. 30, no. 3 (2004), and Richard A. Wright et al., 
"Finding the Medically Underserved: A Need to Revise the Federal 
Definition," Journal of Health Care for the Poor and Underserved, vol. 
7, no. 4 (1996). 

[54] Robst and Graham, "The Relationship between the Supply of Primary 
Care Physicians and Measures of Heath." 

[55] See, for example, Council on Graduate Medical Education, 
Department of Health and Human Services, Health Resources and Services 
Administration, Tenth Report: Physician Distribution and Health Care 
Challenges in Rural and Inner-City Areas, and Taylor and Ricketts, 
"Examining Alternative Measures of Medical Underservice for Rural 
Areas: Executive Summary." 

[56] Taylor and Ricketts, "Examining Alternative Measures of Medical 
Underservice for Rural Areas: Executive Summary." 

[57] Office of Inspector General, Department of Health and Human 
Services, Status of the Rural Health Clinic Program, OEI-05-03-00170 
(Chicago: August 2005). The Inspector General's review was limited to 
those HPSAs where rural health clinics were located. HRSA stated in its 
response to this report that the actual submission of updates of HPSA 
data by interested parties and groups, and the review and action for 
existing HPSA designations by HRSA, took place after the fourth or 
possibly fifth year after a HPSA designation was received. HRSA also 
stated that its ability to review depended on the number of requests 
HRSA received for individual HPSA updates and the complexity of those 
requests. 

[58] 67 Fed. Reg. 7740-88 (Feb. 20, 2002). 

[59] According to HRSA officials, the impact of not publishing a list 
of designated HPSAs in the Federal Register may have been lessened 
because (1) HRSA has a publicly available Web-based application that 
can be used to search a regularly updated, real-time database of HPSA 
designations, including those proposed for withdrawal, and (2) NHSC, 
for which the HPSA designations were originally developed and the major 
reason for the designations, does not place providers in HPSAs that are 
proposed for withdrawal, so the absence of the Federal Register 
publication has not affected the practice locations for NHSC programs. 
HHS officials also noted that, for other programs that use the HPSA 
designation, the decision to use or not use HPSAs proposed for 
withdrawal is generally made by the individual programs. 

[60] Of the 2,746 geographic and population-group HPSAs designated as 
of January 2006, about 12 percent were proposed for withdrawal because 
they no longer met the criteria or had not provided HRSA with updated 
data in support of their designations. 

[61] One tribal health center had not received a HPSA score from HRSA 
as of September 2005. Although health centers receiving automatic 
designation could also use the score of a geographic or population- 
group HPSA if the facility was located in one, HRSA officials we spoke 
with did not have data on how many health centers that were eligible 
for this provision chose to use it when applying for federal programs. 

[62] In addition to the NHSC Loan Repayment Program, health centers 
with automatic facility HPSA designations were eligible to apply for 
other programs that did not require a HPSA score, such as J-1 visa 
waiver programs administered by the Appalachian Regional Commission, 
the Delta Regional Authority, and many state health departments. 

[63] See John A. Gale and Andrew F. Coburn, The Characteristics and 
Roles of Rural Health Clinics in the United States: A Chartbook, 
(Portland, Me.: Maine Rural Health Research Center, Institute for 
Health Policy, Edmund S. Muskie School of Public Service, University of 
Southern Maine, 2003). In addition, our analysis of data prepared for 
HRSA's Office of Rural Health Policy using 2003 and 2004 CMS data on 
rural health clinics and 2005 HRSA data on HPSAs indicated that nearly 
half of all rural health clinics--including those that did not receive 
automatic designation--were located in geographic or population-group 
HPSAs. 

[64] As of September 2005, 7 of the 590 rural health clinics that 
received automatic HPSA designation had not received a HPSA score from 
HRSA. Although rural health clinics receiving automatic designation 
could also use the score of a geographic or population-group HPSA if 
the facility was located in one, HRSA officials we spoke with did not 
have data on how many rural health clinics that were eligible for this 
provision chose to use it when applying for federal programs. 

[65] In addition to the NHSC Loan Repayment Program, rural health 
clinics with automatic facility HPSA designations were eligible to 
apply for other programs that did not require a HPSA score, such as J- 
1 visa waiver programs administered by the Appalachian Regional 
Commission, the Delta Regional Authority, and many state health 
departments. 

[66] Criteria for designation of MUAs and MUPs are based on the index 
of medical underservice, published in the Federal Register on October 
15, 1976, and on the provisions of Pub. L. No. 99-280, enacted in 1986. 
Areas or populations are scored on a scale of 0 to 100, where 0 
represents completely underserved and 100 represents best served or 
least underserved. Each service area or population group within an area 
found to have a score of 62 or less qualifies for designation as an MUA 
or MUP. See HRSA, Bureau of Health Professions, "Guidelines for 
Medically Underserved Area and Population Designation," 
http://bhpr.hrsa.gov/shortage/muaguide.htm (downloaded on June 23, 
2006). 

[67] 63 Fed. Reg. 46538-55 (Sept. 1, 1998). 

[68] Funding preferences are factors that place a grant application 
ahead of others without a preference on a list of applicants 
recommended for funding by a review committee. 

[69] 42 U.S.C. § 295p(6). In fiscal year 2005 guidance to grant 
applicants, HRSA stated that medically underserved communities include 
health centers (including those for migrant workers, the homeless, and 
residents of public housing); rural health clinics; National Health 
Service Corps (NHSC) sites; Indian Health Service (IHS) sites; HPSAs; 
state or local health departments; and sites in a shortage area 
designated by a state governor. 

[70] 42 U.S.C. § 295j. An additional grant program authorized under 
title VII of the Public Health Service Act provides a funding 
preference for applicants that have not less than 25 percent of their 
graduates in full-time practice settings in medically underserved 
communities, that recruit and admit students from medically underserved 
communities, that have established relationships with public and 
nonprofit providers of health care in the community involved, and that 
emphasize employment with public and nonprofit entities in their 
training of students. 42 U.S.C. § 295d(c). 

[71] 42 U.S.C. § 296d. The preference also applies to applicants that 
will help meet public health nursing needs in state or local health 
departments. 

[72] The HRSA Geospatial Data Warehouse provides a single point of 
access to HRSA programmatic information, related health resources, and 
demographic data for reporting on HRSA activities. The data warehouse 
provides access to information for reporting and mapping of HRSA data, 
including HPSAs. For more information, see HRSA, "HRSA Geospatial Data 
Warehouse," http://datawarehouse.hrsa.gov (downloaded Mar. 12, 2006). 
We downloaded data on HPSA designations as of September 2005 from the 
data warehouse on October 27, 2005. We limited our analysis of the HPSA 
database downloaded from the data warehouse to those data elements that 
we determined, following discussion with HRSA officials, were reliable 
for our purposes. 

[73] We downloaded data on HPSA designations as of January 2006 from 
HRSA's Geospatial Data Warehouse on March 12, 2006. 

[74] As of May 2006, the HRSA official responsible for designating 
HPSAs said that the agency was in the process of removing the duplicate 
entries of health centers for Alaska Natives so these facilities would 
be counted only once as a facility HPSA in HRSA's databases. The HRSA 
official also reported that HRSA would remove duplicate public or 
nonprofit medical facilities when these HPSA designations were reviewed 
for continued eligibility. 

[75] We reviewed information from these same sources to obtain 
information on federal programs that use other federal designations of 
medical underservice. 

[76] The factors used to calculate the HPSA score were also generally 
represented in our keywords. 

[77] We identified reports as potentially relevant if they addressed 
the relationship between key elements of the HPSA designation criteria 
and primary care physician shortages or supply, including primary care 
disciplines, such as pediatrics. We determined the following types of 
reports not to be potentially relevant: those specific to other 
disciplines or professions, such as dental care, chiropractic care, 
specialty care, or nursing care; those related to recruitment and 
retention of physicians that focused on physician characteristics; 
those related to workforce projections; those using data from countries 
other than the United States or focusing on health care markets outside 
of the United States; and those with a narrow focus, such as on vaccine 
shortages. 

[78] We excluded reports that used state-level data because these data 
are not necessarily applicable to smaller geographic units such as 
counties, and HPSAs are often based on county boundaries or parts of 
counties. 

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