[Federal Register Volume 71, Number 80 (Wednesday, April 26, 2006)]
[Notices]
[Pages 24724-24731]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: E6-6212]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration


Response to Solicitation of Comments on Proposed Changes to 
Criteria and Process for Assessing Community Need Under the President's 
Health Centers Initiative

AGENCY: Health Resources and Services Administration (HRSA), HHS.

ACTION: Response to solicitation of comments.

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SUMMARY: A notice was published in the Federal Register (FRN) on 
February 4, 2005 (Vol. 70, No. 23, pp. 6016-6023), detailing proposed 
changes to the Need for Assistance (NFA) Worksheet criteria being 
considered for use in future Consolidated Health Center New Access 
Point (NAP) grant cycles. The FRN requested public comments on these 
proposed changes and on the degree to which Need should be weighted 
relative to the other criteria used in the NAP application scoring 
process. Comments were to be provided to HRSA by March 7, 2005.
    The proposed changes to the NFA Worksheet criteria and the 
solicitation of comments were motivated by HRSA's continuous efforts to 
improve its grant processes. To that end, HRSA sought comment on how to 
improve its measure of need for comprehensive primary and preventive 
health care services in the service area or population to be served by 
a NAP applicant, and whether the weighting of need relative to other 
application review criteria should be increased.
    Comments were received from over 50 organizations and/or 
individuals regarding the proposed changes. These comments were 
thoroughly evaluated. This FRN presents a summary of the comments 
received by topic, with HRSA's corresponding responses, and a summary 
of the final changes HRSA has decided to make to the NFA Worksheet and 
the weighting of Need in the application review process.
    Authorizing Legislation: Section 330(e)(1)(A) of the Public Health 
Service (PHS) Act, as amended, authorizes support for the operation of 
public and nonprofit private health centers that provide health 
services to medically underserved populations. Similarly, section 
330(g) authorizes grants for delivery of services to Migratory and 
Seasonal Agricultural Workers; section 330(h) to Homeless populations; 
and section 330(i) to residents of Public Housing.
    Reference: For the previous NFA Worksheet criteria and previously 
used application weights, see Program Information Notice (PIN) 2005-01, 
entitled (Requirements of Fiscal Year 2005 Funding Opportunity for 
Health Center New Access Point Grant Applications.''
    Background: The goal of the President's Health Centers Initiative, 
which began in fiscal year (FY) 2002, is to increase access to 
comprehensive primary and preventive health care services through 
development of new and/or significantly expanded health center access 
points in 1,200 of the Nation's neediest communities. Funded health 
centers are expected to provide comprehensive primary and preventive 
health care services in areas of high need that will improve the health 
status of the medically underserved populations to be served and 
decrease health disparities. Services at these new access points may be 
targeted toward an entire community or service area or toward a 
specific population group in the service area that has been identified 
as having unique and significant barriers to affordable and accessible 
health care services.
    It is important that NAP grant awards be made to entities that will 
successfully implement a viable and legislatively compliant program for 
the delivery of comprehensive primary health services. It is also 
essential that all NAP applicants demonstrate the need for such 
services in the community/population to be served and be evaluated on 
that need.
    As part of its efforts to improve the needs assessment process, 
HRSA arranged for an external evaluation of the NFA Worksheet criteria 
and the use of need factors in the overall application review process. 
The evaluation was conducted by a team consisting of HSR, Inc. and the 
University of North Carolina's Cecil G. Sheps Center for Health 
Services Research. Key results of the evaluation analyses were 
presented in the FRN, as well as recommendations for proposed changes. 
Comments were solicited for the proposed changes.
    A summary of the comments received from the public and HRSA's 
response to these comments are presented below.

Summary of General Comments on Need and NFA Revision Topics

Timing of Implementation

    Issue: The FRN indicated that the second round of funding of FY 
2005 NAP applications was being delayed, pending receipt and 
consideration of public comments on the proposed changes to the NFA 
Worksheet criteria.
    Comments: Comments on timing of implementation reflected the fact 
that two application cycles had been announced for FY 2005. 
Applications had been submitted for consideration under the first 
deadline of December 1, 2004, and a second round application deadline 
of May 23, 2005, was anticipated. At the time of the FRN, no 
applications had been submitted for the second cycle. Comments 
indicated a concern that changing the process of determining NAP awards 
in the middle of the FY 2005 cycle could potentially result in 
significant costs to applicants to revise and resubmit their NAP 
application per the new NFA Worksheet criteria and could be unfair to 
applicants in the second cycle since NAP applications funded from the 
first round in FY 2005 would be reviewed using different NFA Worksheet 
and weighting of Need. HRSA was urged not to make such a change in the 
middle of a funding opportunity.
    Response: HRSA will implement the revised NFA Worksheet in future 
NAP funding opportunities, in a manner which will assure consistency 
within each funding announcement.

Relative Importance of Need as an Application Review Factor

    Issue: The FRN stated that the evaluation team had recommended 
increasing the weight of Need in the application review process from 
the present 10 percent for a narrative ``description of service area/
community and target population'' to 20 percent applied to the NFA 
Worksheet score. The FRN requested public comments on what percentage 
of the total application score should be devoted to Need, and whether 
that should be derived from an objective revised NFA Worksheet score or 
in some other manner.
    Comments: Comments indicated general concurrence that additional 
points should be allocated to the assessment of Need and supported 
allocation of at least 20 percent of the total application score to 
Need. Additionally, comments indicated that the existing narrative 
description of the service area/population Need should be retained, 
especially since it formed the basis for other sections of the 
application which describe how the

[[Page 24725]]

health care needs of the area's population will be addressed through 
the proposed project.
    Response: HRSA will increase the weight of Need within the NAP 
application to a level of slightly more than \1/3\ (35 percent) of the 
total application score. The following strategy has been adopted to 
combine the use of objective measures of Need with a continued role for 
narrative description of Need:
     The quantitative need score derived from the revised NFA 
Worksheet (discussed in detail below) will account for up to 25 points 
out of 100 total points in the overall score for the application. The 
NFA Worksheet will be scored out of 100 points using the scoring 
criteria included in the application guidance. The NFA Worksheet score 
will then be converted to account for up to 25 points (25 percent) of 
the total overall application score.
     10 points (10 percent of the total overall application 
score) will continue to be dedicated to a narrative description of Need 
in the application.

Where Should Additional Points for Need Come From?

    Issue: In the FRN, the evaluation team suggested reducing the 
points allotted for Governance from 10 percent to 5 percent, and 
reducing the points allocated to ``Service Delivery Strategy and 
Model'' from 20 percent to 15 percent, to accommodate increasing Need 
from 10 percent to 20 percent.
    Comments: Comments expressed specific concern regarding drawing 
points away from the Governance criterion. Comments suggested that 
points instead should be taken from Impact, Evaluative Measures, or 
Response, or alternatively, that all other criteria should be 
proportionally reduced to accommodate the increase in Need.
    Response: To accommodate the inclusion of the NFA Worksheet score 
within the total application score and to assure that the weighting of 
the Governance criterion is not changed, HRSA will reassign points 
among the remaining narrative criteria.

Use of NFA as Eligibility Factor for ORC Review

    Issue: To date, the NFA Worksheet has been used as a screening 
tool, with only those applicants that achieved a total NFA Worksheet 
score of 70 or higher out of the possible 100 points having the merits 
of their application evaluated by the Objective Review Committee (ORC). 
The FRN proposed using a threshold of a score of 50 for future 
applications, but also requested comment on the concept of varying the 
threshold from year to year to maintain a certain ratio of applications 
reviewed to number of awards available.
    Comments: Comments advised against changing the threshold from year 
to year and expressed concern that a threshold of 50 might be too low 
to target the neediest communities.
    Response: HRSA has incorporated the NFA Worksheet score directly 
into the total application scoring process for NAP applications. 
Therefore, HRSA will no longer utilize the NFA Worksheet score as a 
screening mechanism thus eliminating the need for a score threshold.

Data Issues for Special Populations (e.g., Homeless, Migrant and 
Seasonal Farmworkers)

    Issue: Operating grants for primary health care services under 
section 330 may be made for delivery of services to the general 
population of a medically underserved service area (under section 
330(e)), and/or to the migrant and seasonal farmworker population of an 
agricultural area (under section 330(g)), and/or to a homeless 
population (under section 330(h)), and/or to residents of public 
housing (under section 330(i)). The same NFA Worksheet is used for all 
NAP applications targeting one or more of these areas and/or groups. 
Most data for the general population of an area is available at least 
at the county or county-equivalent level, and sometimes for subcounty 
areas (such as census tracts, county divisions, or zip codes), although 
some indicators are only available at the State or hospital district 
level. Data availability for special populations such as migrants and 
the homeless is much less generally available.
    Comments: Some comments suggested that because of data availability 
issues, both the existing NFA Worksheet criteria and those being 
proposed in the FRN make it difficult for migrant or homeless 
populations to demonstrate levels of need comparable to or exceeding 
those of serving general populations in a geographic service area. The 
comments suggested that no change be made until better methods could be 
devised for adequately measuring the needs of these special 
populations, that the proposed criteria not be used for these 
populations, or that more flexibility be allowed for applicants 
proposing to serve such populations when citing data sources. Other 
comments suggested the use of data for migrant populations in 
neighboring States if the applicant's State does not have such data, or 
alternatively, the use of regional or even national data on migrant or 
homeless populations generally, where data for the local special 
population group are unavailable.
    Response: HRSA recognizes that obtaining needs-related data on 
migrant and homeless populations is typically more difficult than 
obtaining similar data for the general population of a service area. 
Therefore, HRSA has incorporated greater flexibility for applicants who 
propose to serve such populations when preparing NFA Worksheets. The 
use of national, regional, or neighboring State data will be allowed in 
estimating the needs of such populations, where justified by the 
absence of State or local data.

Use of Data Based on Service Area vs. Target Population

    Issue: The FRN contained tables showing the proposed indicators, 
scales, and benchmarks to be used with new NFA Worksheet criteria; 
these included instructions to ``give the most current value for an 
area or population group which most closely approximates the proposed 
service area and/or target population.''
    Comments: Some comments indicated concern that applicants would 
inappropriately use ``target population'' as a means of ``gaming'' the 
scoring system. For example, by defining the target population as the 
population with incomes below 200 percent of poverty, an applicant 
could potentially get the full 15 points for that variable, even though 
the service area also included populations with incomes above the 200 
percent of the poverty level. These comments also suggested that 
responses for the NFA Worksheet indicators should be reflective of the 
total service area population not a particular subpopulation. In 
contrast, other comments also raised the issue that, for projects 
serving certain populations, service area data is an incomplete and 
inadequate representation of the characteristics of the particular 
population being targeted in the application.
    Response: In response to concerns that HRSA needs to better define 
the target population in order to reduce ``gaming,'' HRSA has clarified 
the instructions in the NFA Worksheet. Responses to the NFA Worksheet 
will need to be based on data about the service area proposed in the 
NAP application, except if the applicant is proposing to serve a 
special population, as defined in statute. Organizations proposing to 
serve migrant, homeless and/or public housing population (as per 
section 330(g), (h), and (i)

[[Page 24726]]

respectively), may adjust the data presented based on special target 
populations in that area, per the following approach:
     Applicants requesting funding to serve the general 
population of a service area (under section 330(e)) must provide 
responses on the NFA Worksheet that reflect the total population within 
the defined service area for the application. When sub-county level 
data are not available, applicants may use extrapolation or imputation 
techniques to appropriately weight the available county or higher-level 
data to reflect the demographics of their service area population. 
(These techniques will be described in the Data Resource Guide 
available on the HRSA Web site online at: http://www.bphc.hrsa.gov/chc.)
     Applicants requesting funding to serve ONLY homeless 
populations (under section 330 (h)), migrant/seasonal farmworkers 
(under section 330(g)) and/or residents of public housing (under 
section 330(i)) must provide responses on the NFA Worksheet which 
reflect that specific population(s) within the service area. When 
specific population data are not available, applicants may use 
extrapolation or imputation techniques to appropriately weight the 
available county or higher-level data to reflect the demographics of 
their target population. (These techniques will be described in the 
Data Resource Guide available on the HRSA Web site online at: http://www.bphc.hrsa.gov/chc.)
     Applicants requesting funding to serve the homeless (under 
section 330 (h)), and/or migrant/seasonal farmworkers (under section 
330(g)) and/or residents of public housing (under section 330(i)), in 
combination with the general population (under section 330(e)), must 
present responses on the NFA Worksheet that reflect, as closely as 
possible, all of the populations to be served. In calculating the 
response, applicants may use extrapolation techniques to appropriately 
weight each measure to reflect the homeless, migrant/seasonal 
farmworkers, or public housing population within the service area. For 
the portion of the response that reflects the general population, data 
should be based on the population within the defined service area. When 
sub-county level data are not available, applicants may use 
extrapolation or imputation techniques to appropriately weight the 
available county or higher-level data to reflect the demographics of 
their service area population. (These techniques will be described in 
the Data Resource Guide available on the HRSA Web site online at: 
http://www.bphc.hrsa.gov/chc.)

Availability of Data Sources for Barrier and Disparity Indicators

    Issue: Availability of data has been a concern and challenge in 
completing the NFA Worksheet. Applicants have noted the difficulty of 
obtaining data for particular indicators and especially in finding 
reliable and valid data at the local, service area level.
    Comments: Comments addressed a number of issues on this topic. In 
order to facilitate completion of the NFA Worksheet, comments suggested 
that HRSA identify and make available appropriate and acceptable data 
sources, especially if the number of indicators is being reduced. 
Comments also suggested that, to the degree possible, data sources 
should be standardized while still allowing flexibility when local data 
are presented by the applicant, since the availability of data may vary 
widely across States and may not be stable for rural and frontier 
areas. Comments cautioned that if the number of indicators allowed to 
be used in completing the NFA Worksheet is reduced as was suggested in 
the FRN, HRSA should assure that data is available for all of the 
required indicators. Additionally, comments suggested that in cases 
where the use of multi-year data will be required for indicators, the 
number of years should be standardized for consistency and, where State 
or county data is all that is available, HRSA should allow 
extrapolation techniques to estimate values for service areas or target 
populations.
    Response: HRSA has developed a detailed Data Resource Guide 
(accessible on the HRSA Web site online at: http://www.bphc.hrsa.gov/chc) to assist applicants in completing the revised NFA Worksheet. The 
Data Resource Guide identifies data sources for each Barrier and 
Disparity Indicator required or listed as optional on the NFA 
Worksheet. These sources provide data at a county level or a subcounty 
level, or where such local data is not available, State or regional 
data that can be broken down by the categories such as race, ethnicity, 
gender, and/or age for extrapolation to an applicant's service area or 
target population. The Data Resource Guide provides data sources on 
Barrier and Disparity Indicators that are specific to homeless and 
migrant and seasonal agricultural worker populations. Additionally, 
HRSA will allow the use of alternate data sources for many of the 
Barrier and Disparity Indicators, where justified by the presence of 
more specific and/or current data for the service area or target 
population.

Technical Issues on Scales and Benchmarks To Be Used in Needs Scoring

    Issue: Several technical changes are proposed in the new NFA 
Worksheet including revision of the scoring scales used for access 
Barrier indicators; elimination of some of the disparity indicators 
formerly used; further definition of the retained indicators; and 
specification of proposed benchmarks for Disparity indicators.
    Comments: Comments addressed the inclusion, exclusion, or 
definition of certain indicators as well as the methods used to define 
the data ranges, scales, and benchmarks used for scoring the Barrier 
and Disparities indicators. Comments specific to particular indicators 
are addressed below. Some comments on the scoring scales suggested that 
the data ranges were too broad; others suggested that they were too 
restrictive. Comments also cited jumps in the scoring scales as a 
problem (i.e., jumps from 3 to 6 to 9 to 12 to 15 points, with no 
values between). Additional comments suggested that normative values, 
such as Healthy People 2010 objectives, should be used in the scales 
and benchmarks rather than values drawn from national distributions by 
county.
    Response: In light of the comments received, HRSA has reviewed the 
proposed scoring scales and developed new data ranges and scoring 
scales for the Barrier indicators. In addition, we have established 
standard benchmarks for the Disparities indicators in the revised NFA 
Worksheet. The revised scales will result in a wider distribution of 
need scores across applicants. The revised scales also will have fewer 
``jumps'' in the scale, to increase sensitivity and to represent the 
service area needs with greater accuracy. The following breakdown 
provides further information on how the data ranges, scoring scales, 
and benchmarks were determined.
     For each of the Barrier indicators, data ranges for each 
score in the scale are based on comparison to the national county 
distribution of that indicator. The scoring scales for these indicators 
have been expanded to eliminate jumps; each integer score from 1 to 15 
now has a specified data range. No points will be awarded for a Barrier 
indicator value better than the national county median for that 
indicator.
     The benchmarks in the Disparities sections are generally 
based on the distribution of those indicators across all U.S. counties. 
Applicants demonstrating that the areas and/or populations to be served 
have current

[[Page 24727]]

values for the indicators that are worse than the national mean or 
median county value will receive 2 points. For the core indicators, 
applicants demonstrating that the areas and/or populations to be served 
have values in the worst quartile of all counties on those indicators 
will receive an additional point for a total of 3 points for the 
indicator.

Specific Comments on Proposed Revisions to the NFA Worksheet Barriers--
Indicators and HRSA Responses

Population to FTE Primary Care Physician Ratio

    Issue: The proposed NFA Worksheet criteria would assign various 
score levels based on the population to FTE primary care physician 
ratio within the area to be served, replacing the previous method's 
assignment of the maximum number of points (14) to all projects that 
serve an area or population group that has a Health Professional 
Shortage Areas (HPSA) designation (regardless of the relative levels of 
shortage of different HPSAs) with no points assigned to those areas and 
population groups without a HPSA designation.
    Comments: Comments generally indicated support for the use of a 
population to FTE primary care physician ratio to discriminate among 
service areas with different levels of need. Comments also discussed 
the difficulty in capturing appropriate data for areas that are not 
already HPSA-designated; raised concerns about how to account for cases 
where physicians included in the ratios do not accept Medicaid or low-
income patients; and the particular problems of frontier and other 
rural areas (where the presence of a single physician may suggest an 
adequate local ratio but that physician draws patients from a very wide 
area). Comments suggested that some areas without existing HPSA 
designations may need to conduct expensive surveys to obtain comparable 
data. Finally, comments indicated that the scale did not explain how to 
score areas with zero physicians.
    Response: The use of a ratio rather than the presence of a HPSA in 
the service area allows for scaling of the degree of shortage as well 
as for assignment of relative scores to non-HPSA designated areas. In 
general, the ratio accepted by HRSA's Bureau of Health Professions' 
Shortage Designation Branch is recommended for use for existing HPSAs 
and Medically Underserved Areas (MUAs) or Medically Underserved 
Populations (MUPs). Elsewhere, applicants should work with their 
Primary Care Office or Primary Care Association to establish the 
correct ratio. In cases where there is no physician serving an area or 
population group, a second scale is proposed that scores these areas on 
the basis of their total population. The two scales are consistent with 
each other and a basic assumption that, in general, 1.0 FTE primary 
care physician can adequately serve 1,500 people.

Percent of Population With Incomes at or Below 200 Percent Poverty

    Issue: This indicator is proposed as a required indicator for all 
applicants; previously, it was an optional indicator.
    Comments: Some comments suggested using the percent of population 
with incomes below the poverty level rather than percent of population 
with incomes below 200 percent of the poverty level. Comments also 
indicated concern that the threshold for the minimum score appears high 
at 40.5 percent of the population with incomes below 200 percent of 
poverty and suggested that some points should be received by applicants 
proposing to serve areas with 30 or 35 percent of the population with 
incomes below 200 percent of the poverty level.
    Response: HRSA has reviewed the comments received for changing the 
minimum score threshold and definition of the poverty level. In order 
to ensure programmatic consistency with expectations for the sliding 
fee scale in the program regulations (42 CFR 51c.303(f) and 42 CFR 
56.303(f), HRSA has kept the indicator as required for the percent of 
the population with incomes below 200 percent of the poverty level. To 
address concerns for a wider distribution of scores, HRSA has also 
expanded the scoring scale for the percent of population with incomes 
below 200 percent of the poverty level indicator to give points for all 
areas providing a positive score for any service area showing a 
disparity greater than the median percentage value of all U.S. 
counties.

Percent of Population Uninsured

    Issue: The NFA Worksheet previously asked as an optional indicator 
for ``Percent of Uninsured Individuals in the Target Population,'' but 
accompanying instructions stated ``If information is unavailable, use 
number of individuals below 200 percent of poverty minus the number of 
Medicaid beneficiaries.'' The proposed NFA Worksheet criteria replaced 
this with ``Percent of Population Under Age 65 Uninsured,'' and 
provided a scoring scale where points were given for percentages above 
the national mean.
    Comments: Comments indicated the lack of locally applicable data 
for the variable as a concern. Comments indicated that available data 
on the uninsured generally included the elderly, rather than excluding 
them and that most data on the uninsured is available only at the State 
level or for metropolitan areas. Comments suggested HRSA consider 
methods for imputing State data to local levels or estimating the 
uninsured from local data as in the existing NFA Worksheet. Some 
comments also suggested that the proposed scoring scale was too 
restrictive.
    Response: HRSA recognizes the need to ensure population data is 
available at a local level. Therefore, we will utilize the definition 
for uninsured percentage used by the Census Small Area Health Insurance 
Estimates (SAHIE) program, which is a total population percentage. In 
the Resource Guide that is accompanying the NFA Worksheet, HRSA has 
provided references for county-level estimates of the uninsured that 
are available from the Census Bureau including guidance for adjustment 
of these data to more recent time periods using the SAHIE model. 
Alternative estimates from States that have done small area estimates 
and other models are also available, and may be used if more 
appropriate.

Distance/Travel Time to Nearest Primary Care Provider Accepting New 
Medicaid Patients and/or Uninsured Patients

    Issue: The existing NFA Worksheet Barrier criteria allows the use 
of either travel time or distance to nearest source of care accessible 
to the target population. The proposed version of the NFA Worksheet 
included only ``Distance (miles) to nearest provider accepting new 
Medicaid patients and/or uninsured patients,'' with no reference to 
travel time. Further, the point scale had been revised for this 
indicator.
    Comments: Comments supported reinstating the travel time 
alternative to the distance criterion. This was supported both for 
urban areas, where the use of travel time by public transportation was 
advocated, and for rural areas, to allow consideration of mountainous 
terrain and winding roads. Some comments advocated using distance/
travel time to nearest source of care with a sliding fee scale, rather 
than to nearest providers accepting Medicaid or uninsured patients; 
others suggested distance/travel time to nearest provider in an area 
not HPSA-designated; still others pointed out that any such

[[Page 24728]]

qualification should take into account numbers of patients seen and 
would require expensive surveys. Comments suggested that the point 
scale should be expanded, in part to sharpen the scoring differences 
between those (often sparsely-populated) areas with distances/travel 
times to nearest care on the order of 60 miles/60 minutes, as compared 
with areas with distance/travel time to care closer to 30 miles/30 
minutes. Comments raised questions about what the origin point should 
be for measurement of distance (or time) to nearest source of care--at 
the location of the proposed access point, or at the population center 
of the proposed service area--and whether sources of care within the 
service area must be considered for this calculation if the service 
area has been designated as a HPSA, MUA, or MUP.
    Response: HRSA will utilize both distance and travel time to 
nearest primary care provider accepting new Medicaid patients and/or 
uninsured patients as indicators and will utilize scoring scales for 
each indicator that are appropriate for applicants proposing to serve 
urban, suburban, rural, and frontier areas. Both distance and travel 
time to nearest source of care should be computed from the location of 
the proposed access point rather than from the population center of the 
proposed service area. The calculation of average travel time should 
consider distance between the proposed access point as the origin and 
the specific location of the nearest primary care provider accepting 
new Medicaid patients and/or uninsured patients as the destination.

Percent of Population Linguistically Isolated

    Issue: The existing NFA Worksheet criteria used ``Percentage of 
population aged 5 years or older who speak a language other than 
English at home'' as a measure of language barriers to accessing 
primary care services. The revised NFA Worksheet proposed the variable 
``Percent of Population Linguistically Isolated,'' but did not include 
the explicit definition of this variable.
    Comments: Comments suggested HRSA include a standard definition, 
citing the fact that there are several related census variables. Some 
comments supported the proposed change, indicating that linguistic 
isolation, as measured by the percent of people who do not speak 
English or do not speak it well, is a more relevant access barrier 
gauge than the percent of people who speak a language other than 
English at home which may not clearly indicate inability to speak or 
understand English. Some comments suggested that because there is a 
small number of households nationally that meet the more restrictive 
definition of linguistic isolation (defined as any household in which 
no person 14 years old or over speaks English ``Well'' or ``Very 
Well''), the previous indicator should be retained. Comments also 
suggested that either variable often has limited importance in rural 
areas.
    Response: In response to comments for an explicit definition of 
``linguistic isolation,'' HRSA has chosen a measure utilizing local 
data that is readily available and that accurately represents need 
across different service area. HRSA has decided to utilize the 
indicator ``Percentage of people 5 years and over who speak a language 
other than English at home,'' because of the greater robustness of the 
data and the availability of data from the Census at the county and 
Census Tract level. HRSA has also modified the scoring scale to reflect 
the distribution of the indicator at the county level.

Standardized Mortality Rate or Ratio/Life Expectancy/Age-Adjusted Death 
Rate

    Issue: The FRN identified ``Standardized Mortality Rate'' in the 
text and ``Standardized Mortality Ratio'' in the accompanying table, 
but did not explicitly define either indicator making it unclear which 
factor was to be utilized. In addition, the breakpoints specified for 
this variable appeared to be consistent with the variable ``Life 
Expectancy'' in years (used in the existing NFA Worksheet criteria), 
rather than with a mortality rate or ratio.
    Comments: Comments requested clarification and indicated that there 
was limited data availability on ``Standardized Mortality Rate'' or 
``Standardized Mortality Ratio'' at the State level. Some comments 
suggested age-adjusted mortality rate as an alternate indicator while 
others suggested continued use of the Life Expectancy variable.
    Response: HRSA acknowledges the comments regarding the need for 
greater clarity on the specific indicator that will be used. Therefore, 
we have decided to utilize age-adjusted death rate as the Barrier 
measure because this data is available at the local level. In contrast, 
``Life Expectancy'' data is not regularly reported for small areas. 
Age-adjusted death rate is available indirectly from the National 
Center for Health Statistics for each U.S. county (using their analysis 
facilities) and from most State's vital statistics branches. These 
rates are expressed as a number of deaths per 100,000 population. The 
data for individual counties can be downloaded from the Centers for 
Disease Control and Prevention (CDC) WONDER Web site and has been 
referenced in the Resource Guide accompanying the NFA Worksheet.

Unemployment Rate

    Comments: Comments indicated several concerns with the unemployment 
rate indicator including that underemployment and underreporting are 
issues in many low-income, low-access areas; the unemployment rate does 
not reflect situations where individuals are working at minimum wage or 
at several part-time jobs because of inability to find one full-time 
job (most part-time employment provides little or no fringe benefits 
such as health insurance); and available county-level data do not 
necessarily reflect the actual rates for target low-income populations 
within larger service areas.
    Response: HRSA has decided to utilize unemployment rate as an 
access Barrier indicator with the scoring scale adjusted to provide 
points for rates above the national median for counties. Unemployment 
data rates are captured on a regular basis and seasonal and temporal 
trends are included in monthly unemployment statistics gathered by each 
State, unlike other data which are not updated as frequently. The 
regularity of the reporting often captures short term economic trends 
at the local level. Unemployment rates for specific population segments 
are less often available but are reported in some areas based on 
specific survey data.

Waiting Time for Public Housing

    Issue: Only applicants requesting funding to serve homeless or 
public housing residents would be allowed to choose waiting time for 
public housing as a Barrier indicator, a choice previously available to 
all applicants.
    Comments: One comment suggested replacing waiting time with the 
ratio of available housing units to number of families on the waiting 
list. It was also suggested that the waiting time indicator was not an 
effective indicator in areas with no public housing. Some comments also 
recommended that this indicator should be available to all applicants, 
since the availability of affordable housing is an issue for all low-
income populations.
    Response: HRSA has decided to make this indicator available for all 
applicants and to redefine the indicator as ``Waiting Time for Public 
Housing Where Public Housing Exists,'' so that it may only be used by 
applicants whose

[[Page 24729]]

proposed project would serve areas where public housing exists.

Comments on Proposed Disparities Indicators on the NFA Worksheet and 
HRSA Responses

    General Issue: The existing NFA Worksheet criteria allowed 
applicants to provide responses to up to 10 out of a list of 27 
disparity factors, including an ``other'' category definable by the 
applicant. Applicants were awarded 3 points for each of the responses 
that exceeded a threshold defined by the applicant. The FRN proposed to 
(a) Require the applicant to provide data on five ``core'' disparity 
factors and (b) allow applicants a choice of 5 out of 7 additional 
disparity factors or an ``other'' factor specifiable by the applicant. 
The five core factors were asthma, diabetes, cardiovascular, birth 
outcomes, and mental health; the FRN listed one specific indicator 
measure each for asthma, diabetes, and cardiovascular, a choice of two 
for birth outcomes, and a choice of two for mental health. One 
indicator was also specified for each of the 7 optional disparity 
factors. With the exception of two factors, national benchmarks (based 
on the national mean or national county median) were proposed for each 
required or optional indicator measure. In order to receive points, an 
applicant would need to provide a response for each indicator whose 
value exceeded its national benchmark. In addition, for the core 
factors, a higher ``severe threshold'' was defined with an additional 
point awarded for response that exceeded the severe threshold.
    Comments: Comments were generally supportive of the overall 
approach of reducing the number of factors considered, but urged 
caution about the choice of specific indicators used to measure each 
factor, especially the five core factors. Comments raised concern 
regarding the availability of data for many of the indicators listed in 
the FRN, noting that a specific indicator for a factor such as asthma 
might be available in some States/areas but not others. These comments 
suggested a need for more flexibility for applicants to select 
available indicators of a particular factor. Other comments suggested 
HRSA reconsider which indicators should be included under the ``core'' 
factors and which should be included under ``optional'' factors. Some 
comments indicated interest in adding factors relevant to oral health, 
HIV/AIDS, and cancer screening to the ``optional'' group factors.
    Response: As indicated in the comments, HRSA recognizes the need to 
ensure that the proposed disparity indicators are applicable and 
appropriate for each given service area, and that data is available at 
a local level for each indicator. To accommodate these concerns and 
allow for some flexibility within the revised NFA Worksheet, HRSA will 
present several alternative indicators under each core Disparity factor 
and additional choices under the optional Disparity factors, allowing 
applicants to choose an indicator best demonstrating need in their 
proposed service area. The revised approach is intended to provide a 
more balanced and complete picture of the health status and health care 
access needs of a community or population.
    Five (5) required categories of Disparity factors have been created 
that include related measures and allow applicants to choose one from a 
set of several optional indicators within each category. These 
categories are: Diabetes/Obesity; Cardiovascular Disease; Asthma/
Respiratory Disease; Prenatal/Perinatal Health; and Mental Health/
Substance Abuse/Behavioral Health. These five categories include direct 
measures of need and population-based rates of morbidity and mortality 
as well as measures that contribute to health care need. Most of the 
categories include both a mortality rate and a hospitalization rate, 
and include indicators that were commonly selected in the original NFA 
Worksheet. The benchmarks for the mortality rates are drawn from 
national county-level distributions, and benchmarks for the 
hospitalization rates from the Agency for Healthcare Research and 
Quality Prevention Quality Indicators.

Asthma

    Comments: Comments stated the proposed asthma prevalence data would 
be difficult to obtain and suggested alternatives including State 
Behavioral Risk Factor Surveillance System (BRFSS) data on the number 
of adults reporting asthma; emergency room visits for asthma; 
preventable asthma hospitalization data; or school health data that may 
be available by county for the school-age population.
    Response: In response to the comments received, HRSA has decided to 
utilize multiple asthma-related indicators for which data is available 
at a local level, including adult asthma prevalence, adult or pediatric 
asthma hospital admission rates, 3 year average pneumonia death rate, 
and several other alternatives. Data sources for each indicator have 
been provided in the Resource Guide.

Diabetes

    Comments: Comments suggested that diabetes prevalence be used as an 
indicator rather than diabetes mortality. Comments also suggested that 
if a diabetes mortality measure is used, it should include only deaths 
where diabetes is the underlying cause or is a contributing factor as 
indicated in Healthy People 2010 Objective 5-5.
    Response: In light of the comments received, HRSA has decided to 
utilize several indicators that allow applicants flexibility to choose 
either diabetes mortality or diabetes prevalence. Data describing 
diabetes prevalence may be available to applicants either through the 
BRFSS reporting system or from special studies and surveys. In 
addition, some states report BRFSS data at the county level. The 
available data sources for each option have been provided in the 
Resource Guide.

Cardiovascular Disease

    Comments: Comments questioned what International Classification of 
Diseases (ICD) codes the proposed indicator of ischemic death rate was 
meant to encompass and suggested use of a more comprehensive CDC rate 
which would also include rheumatic, hypertensive, and pulmonary heart 
disease. Comments also suggested the use of coronary heart disease 
death rate for consistency with Healthy People 2010.
    Response: Based on comments received, HRSA has decided to utilize 
multiple indicators of cardiovascular disease which correspond to the 
CDC definition, listing the ICD Codes where applicable. The indicator 
options include indicators for rheumatic, hypertensive, ischemic, 
pulmonary, and coronary heart diseases. HRSA has provided available and 
appropriate data sources for each indicator in the Resource Guide.

Birth Outcomes

    Comments: Comments presented several questions about the proposed 
indicators including whether multi-year rates were to be used for 
Infant Mortality Rate (IMR) and Low Birth Weight (LBW) and whether the 
term ``pregnancy'' was meant to include miscarriages and abortions.
    Responses: Based on the comments received, HRSA has decided to 
utilize multiple indicators including IMR, percent births that are LBW, 
and percent of pregnant women entering prenatal care after the first 
trimester. Each State's health authority will have local area IMR and 
LBW data that will allow for reporting of these rates. Three-year or 5-

[[Page 24730]]

year rates are recommended to avoid extreme rates for low population 
areas; this is specifically required for infant mortality rate. 
References providing local data nationally have been included in the 
Resource Guide.

Mental Health

    Comments: Comments stated that data on prevalence of depression was 
difficult to obtain, while data on suicide rate was fairly readily 
available. Comments also suggested that data on shortages of mental 
health providers be used as a measure.
    Response: Based on the comments received and varying data 
availability, HRSA has decided to utilize multiple indicators including 
depression prevalence, suicide rate, and several substance abuse 
indicators. There are locally applicable surveys that focus on 
depression or suicide intention, and HRSA has included data sources for 
all indicator options in the Resource Guide.

Teenage Pregnancy Rate

    Comments: Comments requested clarification of what was intended for 
the definition of teenage pregnancy stating that different States use 
different age ranges.
    Response: As the comments indicate, the classification of teen 
birth rates does not have a standard definition. States report varying 
age ranges. However, data are usually available for births by single 
year groupings. HRSA has decided to utilize percent of births to 
mothers age 15 to 19 as an indicator within the core category of 
Prenatal/Perinatal Health because it was viewed to be the most 
appropriate indicator of need for this category. This age range can be 
constructed from the single year groupings generally reported by 
States.

Substance Abuse

    Comments: Comments stated that very little data on this is readily 
available and suggested the use of data on alcohol-related fatalities, 
drug-related arrests, and State youth risk behavioral surveys.
    Response: In light of the comments, HRSA has decided to utilize 
several indicators of substance abuse within the core category of 
Mental Health/Substance Abuse/Behavioral Health discussed above. HRSA 
has included data sources for indicator options in the Resource Guide.

Immunization Rate

    Comments: Comments suggested that the benchmark for immunization 
rate be updated to the current recommendation for children 19 to 35 
months to receive 4 DTP, 3 Polio, 1 MMR, 3 Hib, and 3 Hepatitis B 
immunizations.
    Response: To address the comments, HRSA has decided to utilize a 
benchmark that has been updated to the 4-3-1-3-3 series. Data for 
immunization is not consistently available at the small area level, but 
some States and localities have developed immunization registries where 
these data can be captured.

Hypertension Rate

    See Comments and Response above for Cardiovascular Disease.

Rate of Respiratory Infection

    Comments: Comments requested clarification on whether this 
indicator was meant to include pneumonia alone, as implied by the 
benchmark used (3-year mortality rate from pneumonia). Comments also 
suggested that finding appropriate data for the indicator cited in the 
FRN (``rate of respiratory infection'') could be a problem in States 
that use a combined mortality rate for deaths from pneumonia and 
influenza rather than for pneumonia alone. Comments requested 
clarification of the indicator and benchmark and one suggested an 
annual rate versus a 3-year rate while another suggested a 5-year rate 
for rural areas.
    Response: In consideration of the comments, HRSA has decided to 
allow the use of respiratory infection as an indicator within the core 
category of Asthma/Respiratory Disease. Further, HRSA has decided to 
include the 3-year average mortality rate for pneumonia as 1 of the 7 
indicators that can be used to address the core category of Asthma/
Respiratory Disease.

Obesity

    Comments: Comments noted that obesity is difficult to measure at 
the community level citing several issues regarding the inconsistency 
of data availability including: In most cases, no county-level data is 
available; State-level data is typically only available for adults 
through BRFSS; local-level data is generally available for children 
only.
    Response: HRSA recognizes that obesity can be difficult to measure 
at the community level. Therefore, HRSA has decided to utilize obesity 
as only one indicator within the core factor of Diabetes/Obesity 
discussed above. We note that some States provide small area estimates 
of obesity via their BRFSS data. In addition, in some communities, 
special studies of obesity prevalence may be available.

Percent of Population Aged 65+

    Comments: One comment noted that the elderly are covered by 
Medicare and suggested replacing this indicator with ``Percent of 
Population under age 18.'' Another comment suggested moving this 
indicator to the Barriers section, pointing out that health care needs 
increase significantly with age and the elderly in rural areas have 
difficulty with access because of lack of public transportation.
    Response: Although the elderly are covered by Medicare, usage of 
health care services tends to be greater for the elderly than other 
populations. Therefore, HRSA has decided to retain percent of 
population aged 65+ as an optional Disparity indicator.

Additional Disparity Factors Suggested

Cancer Screening

    Comments: A number of comments recommended including a cancer-
related indicator as an alternative factor; one suggested that disease 
prevalence or incidence be counted instead of a death rate.
    Response: In response to the comments, HRSA has decided to utilize 
multiple indictors for cancer screening including: no pap test for 
women 18+ in past 3 years; no mammogram for women 40+ in past 2 years; 
and no fecal occult blood stool test for adults 50+ in the past 2 
years.

Unintentional Injury Deaths

    Comments: Comments supported inclusion of unintentional injury 
deaths as a Disparity indicator.
    Response: As the comments indicate, unintentional injury deaths can 
be an important Disparity indicator. Therefore, HRSA has decided to 
retain unintentional injury deaths as an optional Disparity indicator. 
Mortality indicators for unintentional injury are compiled and reported 
for counties and other jurisdictions. These data are linked to the 
vital statistics reporting systems but are often listed separately.

Oral Health

    Comments: Comments suggested that oral health is an important 
marker for overall health status and many health centers are placing 
greater emphasis on oral health interventions.
    Response: HRSA agrees with the comments and thus has decided to 
utilize percent of population without a dental visit in the last year 
as an optional Disparity indicator for oral health.

HIV Seroprevalence

    Comments: Comments suggested including a measure of HIV/AIDS

[[Page 24731]]

impact and/or other indicators of communicable disease including 
sexually transmitted disease.
    Response: Based on the comments received, HRSA has decided to 
utilize HIV infection prevalence as a Disparity indicator. HRSA has 
included data sources for HIV infection prevalence in the Resource 
Guide.

Other Disparity Factors

    Comments: Comments noted that the proposed NFA Worksheet no longer 
included certain health-related measures that were important to 
specific communities or special populations and that some provision 
should be made to allow applicants to present health disparity data 
that was specific to the community/population to be served.
    Response: In recognition of the comments, HRSA has decided to 
utilize two ``other'' indicators as optional Disparity factors.

Summary of Proposed Changes to the NFA Worksheet and Application Review 
Process

    NAP applicants are expected to provide comprehensive primary and 
preventive health care services in areas of high need that will improve 
the health status of the medically underserved populations to be served 
and decrease health disparities. The new NFA Worksheet is designed to 
present a balanced and complete picture of the health status and health 
care access needs of the targeted community or population. Through the 
new NFA Worksheet, HRSA will continue to request data on critical 
access/barriers to care and health disparities of populations to be 
served by NAP applicants. The NFA Worksheet is intended to provide 
further standardization while also allowing flexibility for applicants 
to represent the unique and significant health care needs of the 
community/population to be served.
    Future NAP applications will have the revised NFA Worksheet scored 
by the ORC as part of the complete assessment of the application. The 
NFA Worksheet score of up to 100 points will be converted to account 
for up to 25 points of the overall score for the application. An 
additional 10 points will be assigned to the narrative description of 
Need in the community/population to be served. Through this method, the 
community/need for access to primary care services will reflect 35 
percent of the total application score. While it is important that all 
NAP applicants demonstrate the need for comprehensive primary health 
services in the community/population to be served, it is also essential 
that applications be evaluated on their plan to successfully implement 
a viable and legislatively compliant program for the delivery of the 
comprehensive primary health services. Therefore, the remaining 65 
points will focus on the applicant's plan to address the identified 
health care needs of the community/population through the development 
of a viable and compliant health center new access point.
    The final NFA Worksheet is available on the HRSA Web site online 
at: http://www.bphc.hrsa.gov/chc. This NFA Worksheet reflects comments 
received from the FRN and the HRSA decisions discussed in this Notice. 
Future NAP application guidances will also reflect this NFA Worksheet 
and the revised weighting of Need relative to the other criteria used 
in the NAP application scoring process.

FOR FURTHER INFORMATION CONTACT: Preeti Kanodia, Division of Policy and 
Development, Bureau of Primary Health Care, HRSA. Ms. Kanodia may be 
contacted by e-mail at [email protected] or via telephone at (301) 594-
4300.

    Dated: April 19, 2006.
Elizabeth M. Duke,
Administrator.
 [FR Doc. E6-6212 Filed 4-25-06; 8:45 am]
BILLING CODE 4165-15-P