[Federal Register Volume 59, Number 64 (Monday, April 4, 1994)]
[Unknown Section]
[Page 0]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-7876]


[[Page Unknown]]

[Federal Register: April 4, 1994]


-----------------------------------------------------------------------

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration

 

Final Methodology for Implementation of the Statutory General 
Funding Preference for Selected Grant Programs Under Titles VII and 
VIII of the Public Health Service Act for Fiscal Year 1994

SUMMARY: The Health Professions Education Extension Amendments of 1992 
and the Nurse Education and Practice Improvement Amendments of 1992 
(Pub. L. 102-408, dated October 13, 1992) authorize a general funding 
preference (sections 791(a) and 860(e)(1)) for selected grant programs 
in titles VII and VIII of the Public Health Service (PHS) Act. For the 
purpose of making grant and cooperative agreement awards, funding 
preference is defined as the funding of a specific category or group of 
approved applications ahead of other categories or groups of approved 
applications in a discretionary program, or favorable adjustment of the 
formula which determines the grant award in a formula grant program.
    This statutory general preference was implemented in Fiscal Year 
(FY) 1993 following publication of a proposed Federal Register notice 
(57 FR 60212, dated December 18, 1992) which announced the 
implementation methodology for FY 1993. Following public comment, 
modifications were made in the proposed methodology and a final notice 
was published in the Federal Register (58 FR 9570, dated February 22, 
1993). In addition, input was elicited from constituency groups 
affected by this preference provision. The proposed methodology for FY 
1994 implementation of the general funding preference was published in 
the Federal Register (58 FR 40659, dated July 29, 1993). This notice 
will describe the public comments received and will include the final 
methodology for implementation of this statutory funding preference for 
FY 1994.

EFFECTIVE DATE: The methodology for implementing the statutory general 
funding preference which is described in this notice is for use in FY 
1994 grant cycles for the programs which are subject to this funding 
preference.

SUPPLEMENTARY INFORMATION: Sections 791(a) and 860(e)(1) of the PHS Act 
include a general funding preference for selected grant programs under 
titles VII and VIII. Grant programs which are subject to this funding 
preference are:

Departments of Family Medicine (section 747(b)),
Grants for Predoctoral Training in Family Medicine (section 747(a)),
Grants for Graduate Training in Family Medicine (section 747(a)),
Grants for Faculty Development in Family Medicine (section 747(a)),
Grants for Predoctoral Training in General Internal Medicine and/or 
General Pediatrics (section 748),\1\
---------------------------------------------------------------------------

    \1\No competitive cycle planned for FY 1994.
---------------------------------------------------------------------------

Grants for Residency Training in General Internal Medicine and/or 
General Pediatrics (section 748),
Grants for Faculty Development in General Internal Medicine and/or 
General Pediatrics (section 748),
Residency Training and Advanced Education in the General Practice of 
Dentistry (section 749),\1\
Grants for Physician Assistant Training Program (section 750),
Grants for Physician Assistant Faculty Development (section 750),\2\
---------------------------------------------------------------------------

    \2\Program currently in development.
---------------------------------------------------------------------------

Podiatric Primary Care Residency Training (section 751),\1\
Grants for Preventive Medicine Residency Training (section 763),\1\
Allied Health Traineeships (section 766),\1\
Allied Health Project Grants (section 767),
Advanced Nurse Education (section 821),
Nurse Practitioner and Nurse-Midwifery Programs (section 822)
Professional Nurse Traineeships (section 830),
Nurse Anesthetist Education Programs (section 831(a)),
Nurse Anesthetist Traineeships (section 831(a)), and
Grants for Nurse Anesthetist Faculty Fellowships (section 831(b)).

Statutory General Funding Preference Provision

    Under sections 791(a) and 860(e)(1) of the Act, with respect to the 
above listed grant programs, preference will be given to any qualified 
applicant that--
    (A) has a high rate for placing graduates in practice settings 
having the principal focus of serving residents of medically 
underserved communities; or
    (B) during the 2-year period preceding the fiscal year for which 
such an award is sought, has achieved a significant increase in the 
rate of placing graduates in such settings.

When program applications are peer reviewed, preference will be given 
only for applications ranked above the 20th percentile of applications 
that have been recommended for approval by the appropriate peer review 
group. In several formula grant programs affected by this preference, 
the applications are not required to be submitted to a peer review 
group.

Statutory Definition of ``Graduate''

    Under sections 791(c) and 860(e)(3), ``graduate'' is defined as an 
individual who has successfully completed all training (and residency 
requirements) necessary for full certification in the health profession 
selected by the individual.

Methodology for Implementation

    In the proposed notice, the public was invited to comment on the 
proposed changes in the definitions of ``high rate,'' ``significant 
increase in the rate,'' and ``medically underserved communities'' and 
on the implementation specifics for new programs and small programs. 
HRSA received 2 comments prior to the end of the comment period. 
Comments regarding each of the proposed areas will be discussed. 
Comments on implementation aspects that were not specifically proposed 
for public comment are not addressed in this notice.

Proposed Definitions of ``High Rate'' and ``Significant Increase in the 
Rate''

    The proposed definition of ``high rate'' is a minimum percent of 
graduates in academic year 1991-92 or academic year 1992-93, whichever 
is greater, who spend at least 50 percent of their worktime in clinical 
practice in the specified settings. The minimum percent for ``high 
rate'' for each program was to be identified in the Federal Register 
announcement for that program and in the program materials. The 
following statements are proposed amplifications of the basic ``high 
rate'' definition. For undergraduate medical education programs 
academic years 1988-89 and 1989-90 were proposed. Preventive medicine, 
public health, dental public health, and public health nurse graduates 
were proposed to be counted if they identify a primary work affiliation 
at one of the qualified work sites. Graduates who are providing care in 
a medically underserved community as a part of a fellowship or other 
educational experience were to be counted.
    The proposed definition of ``significant increase in the rate'' is 
that, between academic years 1991-92 and 1992-93, the rate of placing 
graduates in the specified settings has increased by a minimum percent 
and that not less than 15 percent of graduates from the most recent 
year are working in these settings. The minimum percent for 
``significant increase in the rate'' for each program was to be 
identified in the Federal Register announcement for that program and in 
the program materials.
    One comment received from a professional association suggested that 
the percentage rates published for grant programs which benefitted 
their constituency should be lower. We believe that the percentage 
rates are appropriate. The rates for FY 1994 are similar to the rates 
used in FY 1993. In FY 1993, only 40% of grant applicants for programs 
affected by this preference did not apply for the preference. Of those 
applicants who did apply, 90% met the criteria and did receive 
preference in funding.

Proposed Implementation Specifics for New Programs

    To allow new programs to compete equitably in FY 1994, criteria for 
the general funding preference were proposed which applied only to new 
programs. It was proposed that a new program be defined as any program 
which has graduated less than three classes. After a program has 
graduated three classes, that program will be able to provide the 
information necessary for the general funding preference as defined in 
the law and will no longer be considered a new program.
    It was proposed that a new program would qualify for the general 
funding preference if four or more of the following criteria were met:
    1. The mission statement of the program identifies a specific 
purpose of preparing health professionals to serve underserved 
populations.
    2. The curriculum includes content which will help to prepare 
practitioners to serve underserved populations.
    3. Substantial clinical training experience is required in 
medically underserved communities.
    4. A minimum of 20 percent of the faculty spend at least 50 percent 
of their time providing/supervising care in medically underserved 
communities.
    5. The entire program or a substantial portion of the program is 
physically located in a medically underserved community.
    6. Student assistance, which is linked to service in medically 
underserved communities following graduation, is available to the 
students in the program.
    7. The program provides a placement mechanism for deploying 
graduates to medically underserved communities.
    One respondent suggested that (1) ``substantial clinical training 
experience'' in criteria #3 should be defined; (2) the word ``faculty'' 
in criteria #4 is unclear; (3) criteria #5 should be deleted because 
``the physical location of a program does not determine the practice 
type;'' and (4) criteria #6 should be deleted because student 
assistance does not apply to grants for residency programs. Since this 
preference applies to a wide variety of programs, a single definition 
of ``substantial clinical training experience'' or ``faculty'' could 
not be applied generally. Individual grant programs may develop 
specific definitions if this becomes necessary. Such definitions would 
be included in program application materials. We believe that programs 
located in medically underserved communities will provide an 
opportunity for students to develop skills needed to provide care to 
underserved populations. We do not plan to delete criterion #5. Since 
student assistance is relevant to many of the programs which are 
subject to the general preference, we do not plan to delete criterion 
#6. New residency programs can qualify for the preference based on any 
combination of four other criteria.
    In addition, it was proposed that new programs could also qualify 
for the general funding preference by providing assurance that a 
minimum percent of their prospective graduates have signed commitments 
to practice in medically underserved communities after graduation 
contingent upon receiving some type of student assistance. This minimum 
percent was to be equal to the minimum percentage for ``high rate.''
    One respondent suggested that ``a non-binding agreement is a poor 
indicator of the actual outcome regarding practice in a medically 
underserved community.'' In FY 1993 no programs qualified for the 
general preference based on signed commitments. This option was 
included to provide every fair opportunity for new programs to qualify 
for the preference. However, if we find that no programs qualify for 
the general preference based on signed commitments in FY 1994, we will 
consider deleting this mechanism to qualify for the preference for FY 
1995.

Proposed Implementation Specifics for Small Programs

    For FY 1994, it was proposed that the program materials for grant 
programs whose applicants typically have less than 10 graduates per 
year would request data for the preceding three years which will be 
aggregated to determine whether or not the ``high rate'' has been 
achieved. There were no comments which specifically disagreed with this 
implementation strategy.

Statutory Definition of ``Medically Underserved Community''

    Section 799(6) of the PHS Act defines ``medically underserved 
community'' as an urban or rural area or population that--
    (A) is eligible for designation under section 332 as a health 
professional shortage area;
    (B) is eligible to be served by a migrant health center under 
section 329, a community health center under section 330, a grantee 
under section 340 (relating to homeless individuals), or a grantee 
under section 340A (relating to residents of public housing); or
    (C) has a shortage of personal health services, as determined under 
criteria issued by the Secretary under section 1861(aa)(2) of the 
Social Security Act (relating to rural health clinics).
    For implementation of the general funding preference in FY 1994, it 
was proposed that service in a ``medically underserved community'' 
would include service in the following work settings:

Community Health Centers (section 330)
Migrant Health Centers (section 329)
Health Care for the Homeless Grantees (section 340)
    Public Housing Primary Care Grantees (section 340A)
Rural Health Clinics, federally designated (section 1861(aa)(2) of the 
Social Security Act)
National Health Service Corps sites, freestanding (section 333)
Indian Health Service Sites (Public Law 93-638 for tribally operated 
sites and Public Law 94-437 for IHS operated sites)
Federally Qualified Health Centers (section 1905(a) and (l) of the 
Social Security Act)
Primary Medical Care Health Professional Shortage Areas (HPSAs) 
(facilities and geographic) (designated under section 332) For primary 
care physicians and other health personnel except dentists and nurses
Dental HPSAs (facilities and geographic) (designated under section 332) 
For dentists only
Nurse Shortage Areas (old section 836, currently section 846) For 
nurses only
State or Local Health Departments (Regardless of sponsor--for example, 
local health departments who are funded by the State would qualify.)
Ambulatory practice sites designated by State Governors as serving 
medically underserved communities

    Several concerns were included in the comments related to the 
definition of ``medically underserved community.'' Many of the issues 
identified related to the need for a more comprehensive list of 
practice settings. For example, it was suggested that the list should 
include (1) practices and/or facilities in which 50 percent or more of 
the patients served are Medicaid recipients and (2) practice settings 
located adjacent to medically underserved communities but serving the 
underserved population. These practice settings are outside the scope 
of the current statutory definition of medically underserved community.
    One respondent objected to favoring applicants whose graduates are 
practicing in Federally-subsidized settings while discriminating 
against those applicants whose graduates are serving where special 
designations have not been sought or Federal assistance utilized. 
Because the statutory definition of medically underserved community is 
based on Federal designations, this bias may be unavoidable. However, 
an attempt has been made to make the list as comprehensive as possible, 
within the confines of the law.
    There was one suggestion to ``provide an opportunity for preference 
to be claimed and secured based on affirmation or documentation that 
graduates' practice settings are located in communities or serve 
populations which meet specified eligibility criteria for HPSA or MUA/
MUP designation.'' There were also several questions related to 
practice settings included on the list. For example, one letter stated 
``many state and local government health department work settings 
clearly do not have service to underserved communities as the principal 
focus.''
    While most of the suggestions made by the respondents are options 
that have been considered previously, these suggestions will all be 
reevaluated for consideration in the FY 1995 implementation of this 
preference. We recognize that there are difficulties associated with 
the implementation of this preference and we appreciate the comments 
received regarding our proposed notice.

Final Methodology for Implementation of the Statutory General Funding 
Preference

Definition of ``High Rate''

    ``High rate'' is defined as a minimum percent of graduates in 
academic year 1991-92 or academic year 1992-93, whichever is greater, 
who spend at least 50 percent of their worktime in clinical practice in 
the specified settings. For undergraduate medical education programs 
academic years 1988-89 and 1989-90 will be used. Preventive medicine, 
public health, dental public health, and public health nurse graduates 
can be counted if they identify a primary work affiliation at one of 
the qualified work sites. Graduates who are providing care in a 
medically underserved community as a part of a fellowship or other 
educational experience can be counted.

Definition of ``Significant Increase in the Rate''

    ``Significant increase in the rate'' means that, between academic 
years 1991-92 and 1992-93, the rate of placing graduates in the 
specified settings has increased by a minimum percent and that not less 
than 15 percent of graduates from the most recent year are working in 
these settings.

New Programs

    A new program is defined as any program which has graduated less 
than three classes. After a program has graduated three classes, that 
program will be able to provide the information necessary for the 
general funding preference as defined in the law and will no longer be 
considered a new program.
    A new program will qualify for the general funding preference if 
four or more of the following criteria are met:
    1. The mission statement of the program identifies a specific 
purpose of preparing health professionals to serve underserved 
populations.
    2. The curriculum includes content which will help to prepare 
practitioners to serve underserved populations.
    3. Substantial clinical training experience is required in 
medically underserved communities.
    4. A minimum of 20 percent of the faculty spend at least 50 percent 
of their time providing/supervising care in medically underserved 
communities.
    5. The entire program or a substantial portion of the program is 
physically located in a medically underserved community.
    6. Student assistance, which is linked to service in medically 
underserved communities following graduation, is available to the 
students in the program.
    7. The program provides a placement mechanism for deploying 
graduates to medically underserved communities.
    In FY 1994, new programs can qualify for the general preference by 
providing assurance that a minimum percent of their prospective 
graduates have signed commitments to practice in medically underserved 
communities after graduation contingent to receiving some type of 
student assistance. This minimum percent will be equal to the minimum 
percentage for ``high rate.''

Small Programs

    For FY 1994, the program materials for grant programs whose 
applicants typically have less than 10 graduates per year will request 
data for the preceding three years which will be aggregated to 
determine whether or not the ``high rate'' has been achieved.

Service in ``Medically Underserved Community Work Settings''

    For implementation of this general funding preference in FY 1994, 
it is proposed that service in a ``medically underserved community'' 
will include service in the following work settings:

Community Health Centers (section 330)
Migrant Health Centers (section 329)
Health Care for the Homeless Grantees (section 340)
Public Housing Primary Care Grantees (section 340A)
Rural Health Clinics, federally designated (section 1861(aa)(2) of the 
Social Security Act)
National Health Service Corps sites, freestanding (section 333)
Indian Health Service Sites (Public Law 93-638 for tribally operated 
sites and Public Law 94-437 for IHS operated sites)
Federally Qualified Health Centers (section 1905 (a) and (l) of the 
Social Security Act)
Primary Medical Care Health Professional Shortage Areas (HPSAs) 
(facilities and geographic) (designated under section 332) For primary 
care physicians and other health personnel except dentists and nurses
Dental HPSAs (facilities and geographic) (designated under section 332) 
For dentists only
Nurse Shortage Areas (old section 836, currently section 846) For 
nurses only
State or Local Health Departments (Regardless of sponsor--for example, 
local health departments who are funded by the State would qualify.)
Ambulatory practice sites designated by State Governors as serving 
medically underserved communities

    Dated: March 28, 1994.
John H. Kelso,
Acting Administrator.
[FR Doc. 94-7876 Filed 4-1-94; 8:45 am]
BILLING CODE 4160-15-W