Health Centers: Competition for Grants and Efforts to Measure	 
Performance Have Increased (13-JUL-05, GAO-05-645).		 
                                                                 
Health centers in the federal Consolidated Health Centers program
provide comprehensive primary health care services at one or more
delivery sites, without regard to patients' ability to pay. In	 
fiscal year 2002, the Health Resources and Services		 
Administration (HRSA) began implementing the 5-year President's  
Health Centers Initiative. The initiative's goal is for the	 
program to provide 1,200 grants in the neediest communities--630 
grants for new delivery sites and 570 grants for expanded	 
services at existing sites--by fiscal year 2006. GAO was asked to
provide information on (1) funding of health centers and HRSA's  
process for assessing the need for services, (2) geographic	 
distribution of health centers, and (3) HRSA's monitoring of	 
health center performance.					 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-05-645 					        
    ACCNO:   A29717						        
  TITLE:     Health Centers: Competition for Grants and Efforts to    
Measure Performance Have Increased				 
     DATE:   07/13/2005 
  SUBJECT:   Community health services				 
	     Data collection					 
	     Data integrity					 
	     Federal funds					 
	     Federal grants					 
	     Grant administration				 
	     Health care programs				 
	     Health care services				 
	     Health centers					 
	     Monitoring 					 
	     Performance measures				 
	     Program evaluation 				 
	     Program management 				 
	     Reporting requirements				 
	     HHS Consolidated Health Centers Program		 

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GAO-05-645

United States Government Accountability Office

              GAO	Report to the Honorable Judd Gregg, U.S. Senate

July 2005

HEALTH CENTERS

    Competition for Grants and Efforts to Measure Performance Have Increased

                                       a

GAO-05-645

July 2005

HEALTH CENTERS

Competition for Grants and Efforts to Measure Performance Have Increased

[IMG]

  What GAO Found

Competition for Consolidated Health Centers program funding increased over
the first 3 years of the President's Health Centers Initiative, and HRSA's
process for assessing communities' need for additional primary care sites
is evolving. Program funding, which primarily supported continuing health
center services, increased from fiscal year 2002 to fiscal year 2004.
However, funding for new access point grants, which fund one or more new
delivery sites, decreased by 53 percent during this period. At the same
time, the number of applicants for these grants increased by 28 percent.
As a result, the proportion of applicants receiving new access point
grants declined from 52 percent in fiscal year 2002 to 20 percent in
fiscal year 2004. In fiscal years 2002 through 2004, HRSA funded 334 new
access point grants and 285 grants for expanded services at existing
sites. While HRSA includes an assessment of communities' need for services
in its process for awarding new access point grants, agency officials
indicated that they were not confident that the process has sufficiently
targeted communities with the greatest need. Therefore, the agency is
considering changes to the way it assesses community need and the relative
weight it gives need in the award process.

The number of health centers receiving new access point grants varied
widely by state-from 1 to 57-during fiscal years 2002 through 2004, but
HRSA lacks reliable data on the number and location of health centers'
delivery sites. Although HRSA uses data on the number of delivery sites to
track the progress of the Consolidated Health Centers program, it is not
confident that grantees are accurately identifying delivery sites funded
by the program. Furthermore, in its reporting, HRSA counted each new
access point grant funded in fiscal years 2002 through 2004 as a single
delivery site, although some represent more than one site. HRSA needs to
collect and report accurate and complete delivery site data to give the
agency and the Congress data they need to make decisions about the
program.

HRSA has increased the role of performance measurement in its monitoring
of health centers and has improved its collection of data that could help
measure overall program performance. In 2004, the agency began to use a
new process for on-site monitoring of health centers that focuses on each
center's performance on measures tailored to its community and patient
population. However, the new review generally does not provide
standardized performance information that HRSA can use to evaluate the
health center program as a whole. The agency is using other tools to
collect health outcome data on patients that could help measure program
performance. Continued attention to such efforts could improve the
agency's ability to evaluate its success in improving the health of people
in underserved communities. In addition to developing these data
collection tools, HRSA has taken steps to improve the accuracy and
completeness of its Uniform Data System, a data set that HRSA uses to
monitor aspects of the health centers' performance. For example, HRSA
provided grantees with more detailed instructions on how to identify their
delivery sites.

United States Government Accountability Office

                                    Contents

Letter                                                                   1 
                                         Results in Brief                   3 
                                            Background                      5 
                            Competition for Health Center Funding Has      
                                      Increased, and HRSA Is               
                            Evaluating Its Process for Assessing Need      12 
                        Number of New Access Point Grantees Varies Widely  
                                          by State, but                    
                        HRSA Lacks Reliable Information on Delivery Sites  18 
                            HRSA Has Increased the Role of Performance     
                                          Measurement in                   
                        Monitoring and Improved Its Collection of Health   21 
                        Center Data                                        
                          Health Centers Often Face Challenges Securing    
                                        Specialty Care for                 
                                             Patients                      28 
                                           Conclusions                     29 
                               Recommendation for Executive Action         30 
                                         Agency Comments                   30 
            Appendix I:               Scope and Methodology                32 
           Appendix II:   HRSA's Process for Awarding Grants through the   
                               Consolidated Health Centers Program         35 
                           Distribution of Consolidated Health Centers     
          Appendix III:                    Program New                     
                          Access Point Grants, Fiscal Years 2002 through   41 
                                               2004                        
                           Distribution of Consolidated Health Centers     
           Appendix IV:                      Program                       
                                     Grantees, 2001 and 2003               43 
            Appendix V:  Comments from the Health Resources and Services   
                                          Administration                   45 
           Appendix VI:       GAO Contact and Staff Acknowledgments        47 

Tables    Table 1: Description of Competitive Grants Funded through the 
                         Consolidated Health Centers Program                9 
           Table 2: Review Criteria for New Access Point, Expanded Medical 
                    Capacity, Service Expansion, and Service Area          
                        Competition Grants, Fiscal Year 2004               38 
Figures  Figure 1: Health Centers' Sources of Revenue, 2003 Figure 2:    6 
                  Allocation of Consolidated Health Centers Program        
                    Funding, by Type of Grant, Fiscal Years 2002           
                                    through 2004                           13 
              Figure 3: Disposition of Applications, by Type, Fiscal Years 
                                                                      2002 
                                    through 2004                           15 

Contents

Figure 4:	Health Center Grantees Funded through the Consolidated Health
Centers Program, 2003 19

Abbreviations

BPHC Bureau of Primary Health Care
HHS Department of Health and Human Services
HRSA Health Resources and Services Administration
JCAHO Joint Commission on Accreditation of Healthcare Organizations
OPR Office of Performance Review
PCER Primary Care Effectiveness Review
UDS Uniform Data System

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separately.

A

United States Government Accountability Office Washington, D.C. 20548

July 13, 2005

The Honorable Judd Gregg United States Senate

Dear Senator Gregg:

The nationwide network of health centers in the federal Consolidated
Health Centers program is an important component of the health care safety
net for vulnerable populations, including Medicaid beneficiaries,1 people
who are uninsured, and others who may have difficulty obtaining access to
health care. The centers provide comprehensive primary health care
services-including preventive, diagnostic, treatment, and emergency
services and referrals to specialty care2-without regard to patients'
ability to pay. They also provide enabling services, such as
transportation and translation, that help patients gain access to care. In
2003, through this program, the Department of Health and Human Services'
(HHS) Health Resources and Services Administration (HRSA) was funding
nearly 900 health centers with one or more delivery sites. The health
centers provided comprehensive primary care services to over 12 million
people-including over 4 million Medicaid patients and nearly 5 million
uninsured patients. To increase access to health care for vulnerable
populations, HRSA began implementing the 5-year President's Health Centers
Initiative in fiscal year 2002. The initiative's goals are for the
Consolidated Health Centers program to provide 1,200 grants in the
neediest communities-630 grants to health centers for new primary care
delivery sites and 570 grants to health centers

1Medicaid is a joint federal-state program that finances health insurance
for certain lowincome adults and children.

2Specialty care is health care services provided by medical professionals
with advanced training focused on a specific field, such as cardiology,
dermatology, and orthopedics.

for expanded services at existing sites3- and increase the number of
people served annually to about 16 million by the end of fiscal year
2006.4

Federal community and migrant health centers were established in the
mid1960s, and other types of health centers-such as homeless and public
housing centers-were established subsequently. The Health Centers
Consolidation Act of 1996 created the Consolidated Health Centers program
by combining these various types of health center programs under Section
330 of the Public Health Service Act.5 In fiscal year 2004, funding for
the Consolidated Health Centers program was about $1.6 billion, of which
about $1.4 billion was allocated to grants for health centers. The Health
Care Safety Net Amendments of 2002 reauthorized the Consolidated Health
Centers program through fiscal year 2006.6

In light of the goals of the President's Health Centers Initiative and in
preparation for consideration of the reauthorization of the Consolidated
Health Centers program, you asked us to provide information on the
program, including health centers' efforts to link patients with specialty
care. In this report, we discuss (1) funding of health centers and HRSA's
process for assessing the need for services; (2) the geographic
distribution of health centers; (3) HRSA's monitoring of health center
performance; and (4) health centers' efforts to provide specialty care for
their patients.

To conduct our work, we analyzed national data that HRSA collects from
health centers that receive grants through the Consolidated Health Centers
program. We also reviewed information on health center funding, grant
applications, and grant awards during fiscal years 2002 through 2004. We
assessed the reliability of these data by interviewing agency officials

3New primary care delivery sites are sites that were not previously part
of health centers funded by the Consolidated Health Centers program. These
sites may be newly established facilities or facilities that already
existed at the time their health center first received program funds.
Sites providing expanded services are previously existing program sites
whose health center is receiving additional funds to increase the site's
service capacity.

4HRSA reported that in fiscal year 2001, before the President's Health
Centers Initiative began, the number of primary care delivery sites whose
health centers were receiving Consolidated Health Centers program funding
was 3,317, and the number of people served was 10.3 million.

5Pub. L. No. 104-299, 110 Stat. 3626 (1996) (codified at 42 U.S.C. S:
254b). The Consolidated Health Centers program also funds school-based
health centers.

6Pub. L. No. 107-251, S: 101, 116 Stat. 1621, 1622-27 (2002).

knowledgeable about the data and the systems that produced them, and we
determined that the data were sufficiently reliable for the purposes of
this report. We interviewed HRSA officials and representatives of state
and national health center membership organizations and conducted
structured interviews with officials of 12 health centers in urban and
rural areas of California, Illinois, Pennsylvania, and Texas. We selected
these states because they vary in geographic location and were among the
states with the highest number of health centers. We conducted our work
from August 2004 through June 2005 in accordance with generally accepted
government auditing standards. (For additional information on our
methodology, see app. I.)

Results in Brief	Competition for Consolidated Health Centers program
funding increased over the first 3 years of the President's Health Centers
Initiative, and HRSA's process for assessing communities' need for
additional health center delivery sites is evolving. Program funding,
which primarily supported continuing health center services, increased
from fiscal year 2002 to fiscal year 2004. However, funding for new access
point grants, which fund one or more new delivery sites operated by either
new or existing grantees, decreased by 53 percent during this period. At
the same time, the number of applicants for these grants increased by 28
percent. As a result, the proportion of applicants receiving new access
point grants declined from 52 percent in fiscal year 2002 to 20 percent in
fiscal year 2004. While HRSA includes an assessment of communities' need
for services in its process for awarding new access point grants, agency
officials indicated that they are not confident that the process has
sufficiently targeted communities with the greatest need. Therefore, the
agency is considering changes to the way it assesses community need and
the relative weight it gives need in the award process.

The number of health centers receiving new access point grants varied
widely by state during fiscal years 2002 through 2004, but HRSA lacks
reliable information on the number and location of the delivery sites
where health centers provided care. During this period, about half of the
334 new access point grants HRSA awarded were in 10 states, and the number
of grantees in each state ranged from 1 to 57. While HRSA can provide
information on the geographic distribution of health center grantees, it
does not have reliable information on the number and geographic
distribution of delivery sites where the centers provide care. In its
budget documents and performance reports, HRSA has used the number of
delivery sites it funds to provide information on its progress toward

achieving its health center program goal of increasing the number of
health center access points. Although HRSA mostly uses delivery site data
from its Uniform Data System (UDS), the program's administrative data set,
to measure this progress, the agency is not confident that grantees
accurately report to UDS the sites supported by program dollars. In
addition, HRSA has underestimated the number of delivery sites it funded
in fiscal years 2002 through 2004 by counting each new access point grant
as a single delivery site regardless of how many sites the grant supports.
It is important for HRSA to ensure that it is collecting and reporting
accurate and complete information about the number and location of
delivery sites where health centers are providing care. HRSA officials and
the Congress need this information to make decisions about managing and
funding the health centers program.

HRSA has increased the role of performance measurement in its monitoring
of health centers and has improved its collection of data that could help
measure overall program performance. In 2004, the agency began to use a
new process for on-site monitoring of individual health centers that
focuses on each center's performance on measures tailored to the specific
needs of its community and patient population. The new review also
provides specific feedback to each health center on ways to improve its
performance. However, the new review generally does not provide
standardized performance information that HRSA can use to evaluate the
health center program as a whole. The agency is using other tools to
collect data that could help measure overall program performance. For
example, HRSA is collecting patient-level health outcome data through its
Sentinel Centers Network-a network of health centers designed to be
geographically and sociodemographically representative-and through its
Health Disparities Collaboratives, which collect standardized data on
patients with chronic diseases such as diabetes and asthma. Continued
attention to such efforts could improve the agency's ability to evaluate
its success in improving the health of people in underserved communities.
In addition to developing these data collection tools, HRSA has taken
steps to improve the accuracy and completeness of UDS, which it uses to
monitor aspects of the health centers' operations and performance. For
example, to improve the accuracy of UDS data on health centers' delivery
sites, for 2004, HRSA revised the instructions to health center grantees
for identifying their delivery sites. In providing this new guidance, HRSA
has taken a step toward improving the quality of its information on the
number and location of the delivery sites it funds. However, the agency
will need to carefully assess the effectiveness of the guidance and, if
necessary, take additional steps to ensure that delivery site information
is accurate.

Although Consolidated Health Centers program funding has enabled health
centers to expand the availability of primary care services, health
centers often face difficulty ensuring that patients receive the specialty
care they need. About one-third of health centers provide some specialty
care on site, but health centers more often provide referrals to specialty
care outside the center. Officials from most of the health centers in our
review told us that there was a shortage of certain types of specialists
available to receive referrals and some specialists were not willing to
provide free care for uninsured patients.

We are recommending that the Administrator of HRSA ensure that the agency
collects reliable information from grantees on the number and location of
delivery sites funded through the program and accurately reports this
information to the Congress.

In commenting on a draft of this report, HRSA acknowledged that more
accurate and timely delivery site data would allow for improved management
of the Consolidated Health Centers program and said that the agency has
efforts under way to increase the accuracy of these data. HRSA did not
indicate whether it plans to revise its method of counting delivery sites
for its future reports on the progress of the health centers program to
include all delivery sites funded since the President's Health Centers
Initiative began. We believe that it is important for HRSA and the
Congress to have complete and accurate information on all delivery sites
funded by program dollars.

Background	The Consolidated Health Centers program is administered by
HRSA's Bureau of Primary Health Care (BPHC). In addition to program grants
from HRSA, which constitute about one-quarter of the centers' budgets, the
health centers receive funding from a variety of other sources, including
Medicaid and state and local grants and contracts. (See fig. 1.) In 2003,
health centers reported total revenues of about $5.96 billion.

Figure 1: Health Centers' Sources of Revenue, 2003

Medicaid

Consolidated Health Centers program and other BPHC grantsa

Medicare

Other insuranceb

Payments directly from patients

Other revenuec

State, local, and private grants and contractsd

Source: GAO analysis of HRSA's UDS, Calendar Year 2003 Data: National
Rollup Report, Exhibit A.

Note: Percentages do not total to100 percent due to rounding. Health
centers reported total revenues of about $5.96 billion in 2003.

aOther grants administered byBPHC account for 1 percent of healthcenter
revenue and include grants for capital improvement and management
information systems.

bIncludes private third-party insurance (6 percent) and other public
insurance (3 percent).

cIncludes funding from other federal grants (3 percent), indigent care
programs(4 percent), and nonpatient-related funding not reported elsewhere
(3 percent).

dState and local grants and contracts account for 9 percent and private
grants and contracts, including foundations, account for 3 percent.
Percentages do nottotal to 13 percent due to rounding.

Health centers are required by law to serve a federally designated
medically underserved area or a federally designated medically underserved
population.7 In 2003, 69 percent of health center patients had a family
income at or below the federal poverty level, and 39 percent were
uninsured. In addition, 64 percent of patients were members of racial or

742 U.S.C. S: 254b(a). Criteria for designating a medically underserved
area or population include the ratio of primary medical care physicians
per 1,000 population, infant mortality rate, percentage of the population
with incomes below the federal poverty level, and percentage of the
population age 65 or older. In 2004, the federal poverty level for a
family of four was an annual income of $18,850 in the 48 contiguous states
and the District of Columbia.

ethnic minority populations, and 30 percent spoke a primary language other
than English.8

  Health Center Organization and Services

Health centers are private, nonprofit community-based organizations or,
less commonly, public organizations such as public health department
clinics. The centers are typically managed by an executive director, a
financial officer, and a clinical director. In addition, health centers
are required by law to have a governing board, the majority of whose
members must be patients of the health center.9,10

Health centers are required to provide a comprehensive set of primary
health care services, which include treatment and consultative services,
diagnostic laboratory and radiology services, emergency medical services,
preventive dental services, immunizations, and prenatal and postpartum
care. Centers are also required to provide referrals for specialty care
and substance abuse and mental health services, and although centers may
use program funds to provide such services themselves or to reimburse
other providers, they are not required to do so. In addition, a
distinguishing feature of health centers is that they are required to
provide enabling services that facilitate access to care, such as case
management, translation, and transportation. The health care services are
provided by clinical staff-including physicians, nurses, dentists, and
mental health and

8Information on health center patients is based on UDS data. The
percentages related to income level and race/ethnicity exclude patients
whose status HRSA reported as unknown. The income level of 20 percent of
patients was reported as unknown, and the race/ethnicity of 6 percent of
patients was reported as unknown.

942 U.S.C. S: 254b(k)(3)(H). According to the health centers statute, HRSA
must waive the governing board composition requirement for a center that
proposes to serve homeless, migrant, or public housing populations
exclusively and for those that are located in sparsely populated rural
areas if the center can show "good cause" for the waiver. HRSA's
application guidance indicates that a waiver will be granted only if
applicants show they cannot meet the composition requirement and that
arrangements are in place to ensure appropriate patient input and
involvement. HRSA program guidance indicates that a legal guardian of a
patient who is a dependent child or adult, or a legal sponsor of an
immigrant, may also be considered a patient for purposes of board
representation.

10HRSA and some health center officials we interviewed believe patient
representation on the governing board is key to identifying the health
care needs of the community. Several representatives from health centers
that do not receive Consolidated Health Centers program funding told us
that the governing board requirement for majority patient representation
deters some potential applicants for program funding because of concerns
that the requirement could limit the financial and managerial expertise of
the board.

substance abuse professionals-or through contracts or cooperative
arrangements with other providers. Health center services are offered at
one or more delivery sites and are required to be available to all people
in the center's service area.11 Services must be provided regardless of
patients' ability to pay.12 Uninsured users are charged for services based
on a sliding fee schedule that takes into account their income level, and
health centers seek reimbursement from public or private insurers for
patients with health insurance.

  HRSA's Award Process for Grants Funded through the Consolidated Health Centers
  Program

HRSA uses a competitive process to award grants to health centers. Grant
applications undergo an initial review for eligibility in which HRSA
screens applications based on specific criteria-the applicant must be a
public or private nonprofit entity, the applicant must be applying for an
appropriate grant (e.g., certain grants funded by the program are
available only to existing grantees), and the application must include the
correct documents and meet page limitations and format requirements.13
Independent reviewers who have expertise in the health center program are
selected by HRSA to review and score all eligible applications. The
reviewers score an application by assessing each component of the
applicant's proposal, including descriptions of the need for health care
services in the applicant's proposed service area, how the applicant would
integrate services with other efforts in the community, and the
applicant's capacity and readiness to initiate the proposed services. The
Administrator of HRSA makes final award decisions and is required to take
into account whether a center is located in a sparsely populated rural
area, the urban/rural distribution of grants, and the distribution of
funds across types of health centers (community, homeless, migrant, and
public housing).14 In addition, the Administrator of HRSA also considers
geographic distribution in making award decisions. The scope of a health
center's grant is delineated in its application and consists of its
services, sites, providers, target population,

1142 U.S.C. S: 254b(a)(1). The requirement to serve all people in the
center's service area does not apply to centers that are specifically
funded to serve homeless people, migratory and seasonal agricultural
workers, or residents of public housing. 42 U.S.C. S: 254b(a)(2).

1242 U.S.C. S: 254b(k)(3)(G)(iii).

13HRSA officials told us that, in general, fewer than 10 percent of
applications are deemed ineligible.

1442 U.S.C. S: 254b(p), (k)(4), (r)(2)(B).

and service area. (See app. II for additional information on HRSA's
process for awarding health center grants.)

BPHC administers several competitive grants under the Consolidated Health
Centers program, including new access point, expanded medical capacity,
service expansion, and service area competition grants. (See table 1.)
HRSA approves funding for a specific project period-which can be up to 5
years for existing grantees and up to 3 years for new organizations- and
provides funds for the first year. For subsequent years, health centers
must obtain funding annually through a noncompeting continuation grant
application process in which the grantee must demonstrate that it has made
satisfactory progress in providing services. A grantee's continued receipt
of grant funds also depends on the availability of funding.

Table 1: Description of Competitive Grants Funded through the Consolidated
Health Centers Program

Maximum annual funding for each Type of grant Purpose Eligibility awarded
grant in fiscal year 2004

New access point	To fund additional delivery sites that offer Existing
grantees and $650,000 comprehensive primary and preventive organizations
that health care services currently do not receive

                                program funding

Expanded medical To increase the number of      Existing grantees $600,000 
                    people served                                    
capacity         in a health center's existing                    
                    service area                                     
                    by expanding the capacity of                     
                    existing                                         
                      sites, such as by increasing                   
                                     the number of                   
                    medical providers, expanding                     
                    hours of                                         
                     operation, expanding existing                   
                                      services, or                   
                    adding new types of services                     
                    through                                          
                    contractual relationships                        

Service expansion To create and expand access to mental Existing grantees
$250,000 (oral health-new access) health, substance abuse, and oral health
$160,000 (mental health/substance care services abuse-new access) $150,000
(oral health and mental health/substance abuse-expanded access)

Service area  To open competition Existing grantees   The maximum level of 
                for existing service and                    support is not    
competition  areas when a health  organizations that    expected to exceed 
                center's project                          the previous annual 
                 period is about to  currently do not        level of program 
                       expire        receive                 funding for this 
                                                                      area or 
                                       program funding        population      

                    Source: GAO analysis of HRSA documents.

  HRSA's Monitoring of the Consolidated Health Centers Program

To monitor health centers' performance and compliance with federal
statutes, regulations, and policies, HRSA relies on periodic on-site
monitoring reviews, as well as ongoing monitoring. Through early 2004,
HRSA used BPHC's Primary Care Effectiveness Review (PCER) to provide
periodic on-site monitoring of health center operations. The PCER was
scheduled to occur every 3 to 5 years as a mandatory part of the
competitive grant renewal process when a health center's project period
was about to expire. During on-site PCER visits, a team of reviewers
identified strengths and weaknesses in health center administration,
governance, clinical and fiscal operations, and management information
systems. According to HRSA officials, review team members were generally
not HRSA staff, but contractors. The last PCER review was conducted in
March 2004.

HRSA created a new process for the periodic on-site review of all agency
grantees, including health centers, and reviewers from HRSA's Office of
Performance Review (OPR) began to use this new process in May 2004. OPR
reviews grantees in the middle of their project period-in the second year
for new grantees and in the third or fourth year for existing grantees.
According to HRSA officials, a goal of the OPR performance review process
is to reduce the burden on grantees by consolidating the on-site
monitoring of all HRSA grants to a health center into one comprehensive
review. For example, if a health center receives a Ryan White Title III
HIV Early Intervention grant,15 the OPR performance review covers both the
Ryan White grant and the Consolidated Health Centers program grant(s).
Each health center review team has three or four reviewers; HRSA's goal is
for the reviewers to be OPR staff, who are located in HRSA's regional
offices, with contractors being used to supplement OPR staff only when
necessary. For each health center review, the review team prepares a
performance report describing its findings. As necessary, the report
identifies the health center's technical assistance needs and actions the
center needs to take to ensure its compliance with program requirements.

HRSA also conducts ongoing monitoring of health centers through its
project officers, who serve as grantees' main point of contact with the
agency. Project officers use various tools to monitor compliance with
program requirements and to assess the overall condition of health
centers. For example, project officers review annual noncompeting
continuation

1542 U.S.C. S:S: 300ff-51 through 300ff-78.

grant applications, conduct midyear assessments, and regularly examine
available data, including financial audits and UDS data. They are also
expected to have regular contact with health centers by telephone and
through e-mail and to connect grantees to resources for assistance when
necessary, such as referring a health center to a HRSA-funded contractor
for technical assistance to improve health center operations. In July
2003, HRSA transferred project officer responsibilities from its 10
regional offices and centralized this function within BPHC to improve the
consistency of program oversight.

In addition, about one-third of the health centers funded under the
Consolidated Health Centers program are accredited by the Joint Commission
on Accreditation of Healthcare Organizations (JCAHO) and receive
additional periodic on-site monitoring.16 These reviews include an
assessment of a health center's compliance with program laws and
regulations, clinical procedures, and organizational processes, such as
performance improvement activities and human resource management. HRSA
began promoting accreditation for health centers in 1996, and under its
current agreement with JCAHO, HRSA pays the fees for health center
surveys,17 reducing the financial burden of accreditation for health
centers. HRSA also provides financial support to the National Association
of Community Health Centers to encourage accreditation and educate health
centers about its benefits.

HRSA uses UDS data to monitor aspects of health center and overall program
performance. Each year, health centers are required to report
administrative data on their operations through UDS. These data include a
list of each center's service delivery sites and information about the
center's patients (e.g., race/ethnicity, insurance status); revenues;
expenses; and service, staffing, and utilization patterns. HRSA uses UDS
data to prepare its annual National Rollup Report, which summarizes the
Consolidated Health Centers program; to prepare Comparison Reports, which
allow the centers to compare their performance on certain measures

16JCAHO is a not-for-profit organization that evaluates and accredits more
than 15,000 health care organizations and programs in the United States
using its own standards for the quality and safety of care provided by
health care providers, including hospitals, ambulatory care providers,
nursing homes, and home care organizations.

17The surveys include an initial survey, subsequent triennial surveys,
and, as necessary, laboratory accreditation and behavioral health surveys.

(e.g., productivity, cost per encounter) against that of other centers;
and to generate analyses that HRSA uses when evaluating the program.

In March 2000, we reported on HRSA's monitoring of the Consolidated Health
Centers program.18 We analyzed UDS data from 1996 through 1998 and noted
deficiencies in data completeness and quality. Specifically, some grantees
failed to report certain data elements or reported them very late,
resulting in missing data. Furthermore, we found that the data editing and
cleaning processes that were in place at the time did not always correct
data errors that they were designed to detect. We recommended that HRSA
improve the quality of UDS data and enforce the requirement that every
grantee report complete and accurate data. In response to the
recommendation, HRSA reported that a new requirement was in place for
grantees to submit their UDS reports electronically, which improved the
timeliness and accuracy of data by eliminating the need for a second level
of data entry. In addition, the agency implemented formal training for
centers on how to report UDS data.

  Competition for Health Center Funding Has Increased, and HRSA Is Evaluating
  Its Process for Assessing Need

Competition for new access point, expanded medical capacity, and service
expansion grants increased during the first 3 years of the President's
Health Centers Initiative. For example, while HRSA funding of new access
point grants decreased by about half from fiscal year 2002 to fiscal year
2004, the number of applicants rose by 28 percent. HRSA is concerned that
its current process for awarding new access point grants may not be
consistent with the goal of funding health centers in the neediest
communities. Therefore, the agency is considering both revising the
measures it uses to assess need and increasing the relative weight of need
in the award process.

18GAO, Community Health Centers: Adapting to Changing Health Care
Environment Key to Continued Success, GAO/HEHS-00-39 (Washington, D.C.:
Mar. 10, 2000). This report focused only on community and migrant health
centers.

Funding for Grants to Competition for new access point grants increased
over the first 3 years of Increase Health Center the President's Health
Centers Initiative. Although the majority of grant Services Has Become
More funds are awarded for continuation grants, for which funding
increased,

funding for other types of grants declined. (See fig. 2.) For
example,Competitive Since the funding for new access point grants
decreased from about $80 million in President's Health Centers fiscal year
2002 to about $38 million in fiscal year 2004, a 53 percent Initiative
Began decline.

Figure 2: Allocation of Consolidated Health Centers Program Funding, by
Type of Grant, Fiscal Years 2002 through 2004

                           Dollars in millions 1,500

                                     1,409

                                   1,200 900

                                      600

                                     300 0

2002 2003 2004 Type of grant

Total $1,195 $1,315 $1,409

Source: GAO analysis of HRSA data.

aContinuation grants are noncompeting continuation grants and service area
competition grants.

bBase adjustments are supplemental funding that HRSA awards to existing
grantees to help offset rising costs.

At the same time, the number of eligible new access point applications
increased by 28 percent. Combined with the decrease in new access point
funding, this resulted in a decrease in the proportion of applicants that
HRSA funded-from 52 percent of fiscal year 2002 applicants to 20 percent
of fiscal year 2004 applicants. Some of these applicants received funding
in the same year they applied, and others received funding the following
year.19 (See fig. 3.) The percentage of new access point applicants HRSA
funded in the same year they applied decreased from 43 percent in fiscal
year 2002 to 3 percent in fiscal year 2004. In addition, HRSA approved 17
percent of the applications it received in fiscal year 2004 for funding in
fiscal year 2005.

19HRSA officials told us that awards to be funded in the following year
are contingent on the availability of funds at that time.

Figure 3: Disposition of Applications, by Type, Fiscal Years 2002 through
2004

Note: Eligible applications meet the following criteria: the applicant is
a public or private nonprofit entity, the applicant is applying for an
appropriate grant (e.g., expanded medical capacity and service expansion
grants are available only to existing grantees), and the application
includes the correct documents and meets page limitations and format
requirements.

Competition for expanded medical capacity and service expansion grants
also increased during the President's Health Centers Initiative. Funding
for expanded medical capacity grants decreased from about $56 million in
fiscal year 2002 to about $19 million in fiscal year 2004, and funding for
service expansion grants decreased from about $27 million in fiscal year
2002 to about $9 million in fiscal year 2004. With the decrease in funding
amounts, the percentage of funded applicants also decreased. HRSA funded
66 percent of fiscal year 2002 expanded medical capacity applicants

and 57 percent of fiscal year 2002 service expansion applicants;20 in
fiscal year 2004, it funded 34 percent and 21 percent of the applicants,
respectively.

Although HRSA funded fewer grants to increase health center services
during the second and third years of the President's Health Centers
Initiative, HRSA officials believe program funding for fiscal year 2005
and the President's proposed budget for fiscal year 2006 will allow them
to exceed the initiative's goal.21 From fiscal year 2002 through fiscal
year 2004, HRSA funded 334 new access point grants and 285 expanded
medical capacity grants, representing about half of the initiative's
5-year goal of providing 630 new access point grants and 570 expanded
medical capacity grants.

  HRSA's Process for Assessing Need for New Access Point Grants Has Changed

The process HRSA uses to assess the need for services in a new access
point applicant's proposed service area has changed since the beginning of
the President's Health Centers Initiative. In fiscal year 2002, new access
point applicants were ranked according to both the score they received on
a need-for-assistance worksheet22 and the score assigned by independent
reviewers after they evaluated the technical merit of the application. In
fiscal years 2003, 2004, and 2005, however, HRSA did not use the worksheet
scores to rank applicants. Instead, it used the worksheet scores to screen
applicants; only applicants that scored 70 or higher on the worksheet had
their application forwarded to independent reviewers for an evaluation of
its technical merit. In addition to changing the role of the
need-forassistance worksheet score, HRSA also increased the relative
weight of the need criterion in the application score. In fiscal year
2002, the maximum

20Nine percent of the fiscal year 2002 expanded medical capacity
applicants received their funding in fiscal year 2003.

21Estimated federal funding for the Consolidated Health Centers program
was about $1.69 billion in fiscal year 2005. The President's proposed
budget for fiscal year 2006 allocated about $1.99 billion to the program.

22HRSA uses the need-for-assistance worksheet to measure barriers to
obtaining care and to measure health disparity factors in the applicant's
proposed service area. Barriers to care include the distance or time to
the nearest primary care provider and percentage of the population age 5
years or older who speak a language other than English. Health disparity
factors include the rates of specific diseases and health outcomes, such
as cancer, infant mortality, low-birth-weight infants, and teen pregnancy.
Applicants can score up to 100 points on the worksheet.

need criterion score constituted 5 percent of the maximum total
application score; in fiscal years 2003, 2004, and 2005, the maximum need
criterion score constituted 10 percent of the maximum total score.

HRSA has raised concerns that its current process for assessing the need
for services in a new access point applicant's proposed service area may
not be consistent with the goal of the President's Health Centers
Initiative to fund health centers in the neediest communities. HRSA
reported that the process had resulted in little distinction among
applicants' need-forassistance worksheet scores and that almost all
applicants received a score of 70 or higher. During the first 3 years of
the President's Health Centers Initiative, only 24 of 1,346 applications
scored lower than 70 points. In addition, HRSA reported that the relative
weight assigned to an applicant's description of the need for health care
in its proposed service area (10 percent) might be too low. In light of
these concerns, HRSA commissioned a study to evaluate whether the measures
in the need-forassistance worksheet reflected the relative need of
different applicants and whether the review criteria were weighted
appropriately to ensure that grants were awarded to the neediest
communities. The report, which was issued in November 2003, recommended
several changes, including revising measures in the need-for-assistance
worksheet and increasing the maximum need score from 10 percent to 20
percent of the maximum total

23

score.

In response to these recommendations and feedback from program applicants,
HRSA is considering revising the method it uses to assess the need for
services in new access point applicants' service areas. On February 4,
2005, HRSA issued a Federal Register notice seeking comments on a proposal
to change the measures used in the need-forassistance worksheet and to
substitute the need-for-assistance worksheet for the current need
criterion in the grant application.24 HRSA also sought comments on what
weight the agency should give need in the application score. Comments on
the Federal Register notice were due on March 7,

23Cecil G. Sheps Center for Health Services Research, University of North
Carolina at Chapel Hill and Health Systems Research, Inc., Evaluation of
Need for Assistance Criteria and Weighting of Overall Criteria in the
Requirements of Funding New Start and Expansion Grant Applications for
Health Centers, report prepared at the request of HRSA, November 2003.

24Development of Revised Need for Assistance Criteria for Assessing
Community Need for Comprehensive Primary and Preventive Health Care
Services under the President's Health Centers Initiative, 70 Fed. Reg.
6016-6023 (Feb. 4, 2005).

2005, and HRSA expected to complete its analysis by June 2005. HRSA
reported it would delay the May 23, 2005, due date for new access point
applications until its analysis was complete.25

To further strengthen its ability to award new access point grants in the
neediest communities, HRSA has indicated that it may focus its efforts on
high-poverty counties without a health center delivery site.26 In its
fiscal year 2006 budget justification, HRSA noted that, without special
attention to high-poverty counties, the current award process may result
in some of these counties not having a health center site. For example, it
may be difficult for an applicant in a high-poverty county to demonstrate
its financial viability. In the budget justification, HRSA requested funds
specifically for awarding new access point grants to centers serving
highpoverty counties and planning grants to community-based organizations
to support the establishment of centers in such counties.

  Number of New Access Point Grantees Varies Widely by State, but HRSA Lacks
  Reliable Information on Delivery Sites

The number of health centers receiving new access point grants varied
widely by state during the first 3 years of the President's Health Centers
Initiative.27 During that period, HRSA awarded 334 new access point
grants,28 with at least one grantee in each state.29 About half of the
grantees were in 10 states-Alaska, California, Illinois, Massachusetts,
New Mexico, New York, Oregon, South Carolina, Texas, and Virginia. The
number of grantees in each state ranged from 57 in California to 1 each in
Delaware, the District of Columbia, Kansas, and Wyoming. (See app. III for
additional information on the number of new access point grants by state
and territory. See app. IV for the numbers of all health center grantees,
by state and territory, operating in 2001-before the initiative began-and
in 2003- the most recent year for which data were available at the time we
conducted our review. Figure 4 shows the location of health centers that
HRSA was funding in 2003.)

25May 23, 2005, was the due date for the second round of fiscal year 2005
new access point applications. December 1, 2004, was the due date for the
first round of applications.

26HRSA officials said the agency has not yet determined what constitutes a
high-poverty county.

27Unless otherwise noted, in this report, "states" refers to the 50 states
and the District of Columbia.

28About half of the grants went to health centers that were new to the
program, and about half went to health centers already in the program that
were adding to their delivery sites.

29HRSA also funded grants in American Samoa, Puerto Rico, and the Virgin
Islands.

In 2003, the distribution of all health center grantees was 48 percent
urban and 52 percent rural.30 HRSA is required by law to make awards so
that 40 to 60 percent of patients expected to be served reside in rural
areas.31 HRSA officials told us that the agency meets this requirement by
ensuring that the proportion of awards to rural health centers is from 40
to 60 percent. Based on the numbers of patients reported by health centers
to the UDS, the proportion of patients served by urban health centers in
2003 was 54 percent and the proportion served by rural centers was 46
percent.

While HRSA can provide information on the geographic distribution of
health center grantees, it does not have reliable information on the
number and geographic distribution of the delivery sites where the centers
provide care. In its budget justification documents and Government
Performance and Results Act reports, HRSA has used the number of delivery
sites it funds to provide information on its progress toward achieving its
goals for the Consolidated Health Centers program. For example, in its
fiscal year 2005 performance plan, HRSA has a performance goal of
increasing access points in the health centers program, and it used 2001
UDS data on the number of health center delivery sites as a baseline to
measure progress toward this goal. HRSA, however, is not confident that
UDS data accurately reflect the number of sites supported by program
dollars. HRSA officials told us that the agency does not verify the
accuracy of the delivery site information grantees provide to UDS. They
also said that UDS delivery site data through 2003 may include sites not
funded by the health centers program and sites that HRSA did not approve
in the scope of a health center's grant. Moreover, HRSA has been reporting
inconsistent data on the number of health center delivery sites in the
program. For example, in its fiscal year 2005 performance plan, HRSA
reported funding 3,588 delivery sites in fiscal year 2003, consisting of
3,317 delivery sites operating in fiscal year 2001 and 271 new access
point grants funded in fiscal years 2002 and

30The urban/rural designation is self-reported by health centers in their
grant application. HRSA instructs health centers to classify themselves as
urban or rural based on where the majority of their patients reside. For
example, if a health center is located in an urban area, but more than 50
percent of its patients reside in rural areas, the center should classify
itself as rural.

3142 U.S.C. S: 254b(k)(4). This requirement has applied to all types of
health centers since the programs were consolidated in 1996. Health
Centers Consolidation Act of 1996, Pub. L. No. 104-299, sec. 2, S:
330(k)(4), 110 Stat. 3626, 3639 (1996). Prior to the consolidation, this
requirement applied only to community health centers, and it was added to
their authorizing legislation by the Health Services and Centers
Amendments of 1978, Pub. L. No. 95-626, S: 104(d)(5)(B), 92 Stat. 3551,
3557-58 (1978).

2003; however, some of the new access point grants represent more than one
delivery site. As a result, HRSA underestimated the number of new program
delivery sites operating in fiscal years 2002 and 2003.

  HRSA Has Increased the Role of Performance Measurement in Monitoring and
  Improved Its Collection of Health Center Data

HRSA's new tool for periodic on-site review of health centers-the OPR
performance review-focuses on monitoring individual health centers'
performance on selected measures, including health outcome measures. The
OPR performance review generally does not provide HRSA with standardized
performance information for evaluating the Consolidated Health Centers
program as a whole. However, the agency is using other data collection
tools, such as its Sentinel Centers Network, that could help it measure
overall program performance. HRSA also uses UDS to monitor aspects of
health centers' performance, and the agency has taken steps to improve the
accuracy and completeness of that data set.

  HRSA's New Process for Monitoring Health Centers and Other Data Collection
  Tools Include Patient Health Outcome Measures

HRSA's new health center reviews, conducted by OPR staff, focus on
evaluating selected measures of performance and identifying ways to
improve health centers' operations and performance.32 OPR works with each
health center to select three to five measures that reflect the specific
needs of the center's community and patient population, and then to
ascertain the health center's current performance on each measure.33,34
For the health centers we contacted that had undergone the OPR performance
review,35 most of the measures were health outcome measures. These
measures included the average number of days that asthmatic patients are
symptom free, percentage of patients age 60 or older receiving influenza
and pneumonia immunizations, and percentage of low-birth-weight infants

32As of February 2005, 100 health center reviews had been conducted; an
additional 220 reviews were scheduled to be conducted in 2005.

33If the health center receives grants from other HRSA programs,
additional measures are selected for those grant programs.

34HRSA officials told us that, beginning in January 2005, all health
center reviews began to include the number of patients receiving care as
one measure. They said the agency is exploring the use of additional
measures that would be included in all health center reviews starting in
2006.

35In addition to our interviews of officials from 12 health centers, we
also interviewed officials from 6 other health centers that had completed
an OPR performance review.

born to health center patients.36 Health centers may set performance goals
related to these measures. For example, one health center adopted the goal
set by Healthy People 2010 of reducing the percentage of low-birth-weight
infants born to its patients to less than 5 percent.37 HRSA officials told
us that the agency intends to follow up annually on grantees' performance
on these measures. When possible, HRSA plans to track progress using data
the grantee already reports. For example, HRSA would be able to use UDS
data to track progress on the number of health center patients receiving
care. HRSA officials told us that because the OPR performance reviews
began recently, the agency is still determining how it will track
performance on other measures, including many related to patient health
outcomes.

After assessing the health center's performance on each measure, the
review team analyzes the factors that contribute to and hinder the
center's performance on these measures, including the processes and
systems the health center uses in its operations. During an on-site visit,
the review team meets with health center staff to discuss these factors
and determine which are the most important to address. The review team
also identifies potential actions that could help the center improve its
performance and identifies possible partners in making improvements. For
example, to improve one health center's performance on its
low-birth-weight measure, the review team suggested the center undertake
provider and patient education, training for health center staff,
continued partnerships with other service providers and community groups,
and an analysis of patient medical charts to identify the risk factors of
patients who gave birth to lowbirth-weight infants.

HRSA requires that grantees develop an action plan to improve performance
in response to the review team's findings. The action plan describes the
specific steps the grantee plans to take to improve performance on each
measure and provides estimated completion dates. For example, the health
center discussed above proposed hiring an outside physician to conduct
chart reviews and showing a video on cultural competence to all staff as
two specific actions to improve performance on its low-birth-weight
measure.

36Other measures selected by health centers related to the number of
health center patients receiving care, accuracy of data, and the financial
condition of the health center.

37HHS's Healthy People 2010 is a set of health promotion and disease
prevention objectives for the nation to achieve by 2010.

While the OPR review primarily focuses on health centers' performance on
specific measures, the reviews also verify key aspects of health centers'
compliance with Consolidated Health Centers program requirements. The
review teams examine information HRSA maintains on each health center,
including grant applications and financial audits. According to HRSA
officials, OPR reviewers also follow up on concerns identified by project
officers, who are the agency's primary means for ongoing monitoring of
health center operations and compliance. If the review team identifies any
instances of noncompliance with program requirements-such as those related
to the types of services the center must provide and the composition of
its governing board-HRSA requires grantees to address them in the action
plan.

HRSA officials told us they hoped that in addition to providing
information on individual health centers, the OPR performance reviews
would result in information that could improve other centers' services and
operations. HRSA officials said that as reviewers gained more experience
in evaluating health centers, they would be better able to identify best
practices that contribute to outstanding patient health outcomes and share
these practices among health centers. HRSA officials told us that OPR
planned to use this information to develop a list of successful practices
employed by health centers, such as a patient tracking system or
prescription drug subsidy program. They said they expected to generate
this list three times a year and to make it available as a resource for
project officers and OPR review teams to share with other health centers.

The health center officials we interviewed whose centers had undergone the
OPR performance review said that, in general, it provided helpful
suggestions for improving services and operations.38 Officials from some
health centers told us that they planned to incorporate the performance
goals and their progress in achieving them into their future grant
applications. Health center staff also described the reviews as accurate
and thorough and said they appreciated the in-depth method of looking at
performance in targeted areas. Officials from a few health centers also
noted that their reviewers had expertise on the health centers program

38Health center officials told us their center also used other tools and
local data sources to measure performance and identify areas for
improvement. Some of these tools included UDS data, county and community
health assessments, patient surveys, patient health data, and the center's
governing board. For example, one official told us the center regularly
compared its individual performance with federal and state disease and
infant mortality rates.

because the reviewers had previously been project officers for the
program; one health center official said that this expertise was critical
to the review process. In many cases, HRSA field office staff conduct
performance reviews of health centers in states or communities with which
they are already familiar. HRSA officials told us this experience has
allowed the OPR reviewers to understand performance in the context of the
local, state, and regional environment, such as the effect state Medicaid
funding and policy changes might have on the number of people receiving
health center services.

While the OPR review evaluates the performance of individual health
centers, it generally does not provide standardized performance
information for the Consolidated Health Centers program as a whole, and
HRSA is using other tools to collect information that could help measure
overall program performance. In 2002, HRSA began collecting data on health
centers' services and patient populations through its Sentinel Centers
Network-a network of health centers designed to be geographically and
sociodemographically representative. As of February 2005, 67 health
centers, with more than 1 million patients, were participating in the
network. Participating health centers report patient-, encounter-, and
practitioner-level data.39 The network is intended to supplement HRSA's
other data sources, such as the Community Health Center User and Visit
Survey,40 which is conducted only every 5 to 7 years, and the UDS, which
generally provides grantee-level data.

HRSA also collects information that could help it measure overall program
performance through its Health Disparities Collaboratives, which the
agency views as a tool for improving the quality of care. Participating
health centers use a model for patient care that includes evidence-based
practice guidelines. The model also includes a database in which the
health centers collect standardized patient-level health outcome data that
are used to track progress and are shared with all health centers in the

39Patient-level data elements include sex, ethnicity, race, education
level, smoking status, weight, and blood pressure and cholesterol levels.
Encounter-level data elements include the date the service was provided
and procedure and diagnosis codes. Practitioner-level data elements
include primary and secondary specialties and number of years the
practitioner has been employed by the health center.

40The Community Health Center User and Visit Survey collects information
from about 2,000 health center patients about their health center
experiences.

collaborative.41 HRSA plans to expand the collaborative model from a focus
on specific diseases to a focus on primary care in general. Through 2004,
497 health centers had implemented the collaborative model for at least
one disease. An additional 150 centers began the collaborative process in
February 2005.42 In the future, HRSA officials would like to extend the
model to all health centers in the Consolidated Health Centers program.

HRSA has a contract with Johns Hopkins University for evaluating data from
the Sentinel Centers Network and other health center data, such as UDS
data.43 According to HRSA officials, the purpose of this contract is to
provide timely, short-term statistical analyses and longer-term evaluation
studies using databases that contain information on health centers. One
planned study will examine preventive services provided by health centers,
and several will focus on the role of health centers in reducing
racial/ethnic and socioeconomic disparities in health outcomes for health
center users.

41In 1998, HRSA and the Institute for Healthcare Improvement (a private
not-for-profit organization) developed the first Health Disparities
Collaborative, which focused on diabetes care. Since that time, additional
collaboratives have focused on asthma, depression, cardiovascular disease,
and cancer.

42Health centers participating in a Health Disparities Collaborative
initially go through a 12month training period. Teams from the health
centers attend learning sessions, test and implement changes in practice,
and collect data to measure the impact of these changes on patient health
outcomes in specific disease areas. HRSA's service expansion grants have
included awards to support health centers' continued implementation of the
collaborative model after the training period; 52 health centers in fiscal
year 2003 and 32 health centers in fiscal year 2004 received, on average,
about $40,000 each. HRSA officials told us that these grants are often
used to support centers' infrastructure, such as computer systems for data
management.

43Past studies of the health center program that HRSA conducted with
researchers from Johns Hopkins included a study that examined the role of
health centers in reducing disparities in access to care and a study that
examined the role of health centers in reducing ethnic disparities in
perinatal care and birth outcomes. See Robert Politzer and others,
"Inequality in America: The Contribution of Health Centers in Reducing and
Eliminating Disparities in Access to Care," Medical Care Research and
Review, vol. 58, no. 2 (2001); and Leiyu Shi and others, "America's Health
Centers: Reducing Racial and Ethnic Disparities in Perinatal Care and
Birth Outcomes," Health Services Research, vol. 39, no. 6, Part I (2004).
HRSA also has contracts with other organizations for evaluating health
center data. For example, HRSA has contracts with researchers at Harvard
Medical School and the University of Chicago Medical School to evaluate
the effect of the collaboratives on patient care.

  HRSA Has Taken Actions to Improve the Completeness and Accuracy of Its Uniform
  Data System

Since our previous report on the health centers program in March 2000,44
HRSA has taken steps to improve the UDS data collection and reporting
process by trying to ensure that all Consolidated Health Centers program
grantees report to the system and that the information they report is
complete and accurate. HRSA's efforts resulted in near-universal
reporting-99.8 percent-by grantees for 2003. HRSA contacts grantees that
do not submit UDS data for the preceding calendar year by February

15. HRSA officials told us that after they made several efforts to try to
obtain UDS data, only 2 of the 892 grantees required to report in 2003 did
not submit data.45

To minimize errors in the data set, HRSA implements data quality assurance
procedures in the UDS data collection process. Specifically, HRSA has
programmed 474 edit checks into the software that grantees use to report
UDS data. These edit checks detect mathematical and logical errors and are
triggered while grantees are entering or verifying data. Mathematical edit
checks ensure that rows and columns sum to the total submitted by the
grantee, and logical edit checks ensure consistency within and across
tables. For example, one logical edit check ensures that the total number
of patients reported by age and sex equals the total number of patients
reported by race/ethnicity. The grantee is prompted to address
inaccuracies or inconsistencies identified by the edit checks before
submitting the data to HRSA.

When HRSA receives grantees' UDS submissions, its contractor conducts
additional edit checks. The contractor confirms that grantees' submissions
are substantially complete, which includes ensuring that tables are not
blank, and forwards satisfactory submissions to an editor.46 The editors
review the mathematical and logical checks triggered by the software and
the checks for completeness conducted by the contractor. The editors also
conduct 304 additional edit checks, which include comparisons to data
submitted in the previous year and comparisons to industry norms. When
they find an aberrant data element, editors contact grantees to determine
if

44GAO/HEHS-00-39.

45In 2003, all grantees that had been operating for more than 90 days were
required to submit UDS data.

46When submissions are unsatisfactory, the contractor follows up with
grantees to obtain missing data.

there is an error in the data or if there is a reasonable explanation.47
If there is an error, the editor and grantee agree on a process and
timeline for the grantee to submit corrected data, and the grantee's UDS
data are revised.48 HRSA officials told us that editors were experienced
with UDS, the Consolidated Health Centers program, and data editing. The
editors have also attended training to ensure consistency across editors
and to learn about new edit checks. In addition, editors are assigned to
grantees in a single state or region to facilitate their understanding of
unique regional issues that could affect UDS data, such as managed care
participation.

We found the UDS data for the selected data elements we evaluated to be
generally accurate. For the mathematical and logical edit checks of 25
data elements we conducted, we found very few errors, and each error was
due to missing data.49 In addition, we found no discrepancies in our
replication of five analyses in HRSA's 2003 National Rollup Report.

To improve the accuracy of UDS data on the number and location of health
center delivery sites, for 2004, HRSA revised the instructions to grantees
for identifying their delivery sites. The new instructions specified that
grantees should report delivery sites that provide services on a regularly
scheduled basis and that are operated within the approved scope of the
health center's grant. HRSA also provided more detailed instructions to
help grantees determine which delivery sites they should include in their
UDS submission and which sites they should exclude. As of June 2005, HRSA
had not validated the accuracy of the 2004 UDS data on delivery sites.

47HRSA officials said nearly all submissions generate at least one
potential error that requires an editor to contact a grantee.

48If the editor is unable to obtain accurate data, the information is
rated "questionable" and the editor documents the reason.

49We conducted 25 edit checks for all 890 grantees reporting to UDS in
2003. For 16 of the 25 checks, there were no missing data, 8 checks had
missing data for 1 or 2 grantees, and 1 check had missing data for 12
grantees.

  Health Centers Often Face Challenges Securing Specialty Care for Patients

In addition to providing comprehensive primary and preventive health care
services, most health centers receiving Consolidated Health Centers
program grants provide specialty care on site or have formal arrangements
for referring patients to outside specialists for care. According to the
2003 UDS data, 32 percent of health centers provided some specialty care
on site.50 Specialists providing services on site include health center
employees and volunteers. In addition, 83 percent of health centers
reported that they had formal referral arrangements for some specialty
care,51 which included agreements with community providers, such as local
hospitals and networks of specialty care providers. Almost all of these
health centers reported that they did not pay for some of the services for
which they referred patients. In addition to formal referrals, health
centers also informally refer patients to specialty care. Health center
officials told us that many of their referrals for specialty care were
arranged informally through discussions between health center staff and
the specialty care provider,52 and specialists donated their time to
provide services to the health center's patients.

Health center officials told us that obtaining specialty care for center
patients, especially patients who are uninsured, could be difficult.
Officials from most of the health centers in our review said that there
was a shortage of certain specialists available to receive referrals from
their health center. For example, one official told us that there were
only two specialists providing gynecologic oncology services in the
county, and both physicians were overbooked with paying patients. Health
center officials told us that some specialists-such as orthopedists,
neurologists, oncologists, cardiologists, ophthalmologists, and
dermatologists-were difficult to find.

50UDS defines specialty care as services provided by medical professionals
trained in allergy, dermatology, gastroenterology, general surgery,
neurology, optometry, ophthalmology, otolaryngology, pediatric
specialties, and anesthesiology. UDS also collects data on other specialty
care services-directly observed tuberculosis therapy (delivery of
therapeutic tuberculosis medication under direct observation of health
center staff) and respite care (recuperative or convalescent services used
by people who are homeless and have medical problems but are too ill to
recover on the streets or in a shelter)-and certain professional services,
such as podiatry.

51A formal referral arrangement means the health center either had a
written agreement with the specialty care provider or could document the
service in the patient record.

52In some cases, health centers referred patients to specialty care
services beyond those included in UDS's definition of specialty care, such
as orthopedics, cardiology, oncology, and rheumatology.

This problem is exacerbated because, according to officials from most of
the health centers in our review, some specialists are not willing to
provide free care for uninsured patients. As a result, there are often
long waiting lists for health center patients to see a specialty care
provider who is willing to provide donated services. For example, one
health center official told us that a patient might have to wait 9 months
for an appointment with a dermatologist. One health center official
characterized the center's efforts to secure specialty care for patients
as "begging." Although these issues present a problem for health centers
in both urban and rural areas, people living in rural communities could
face additional challenges affecting their access to care, such as a need
to travel a long distance to obtain care.

Conclusions	HRSA's Consolidated Health Centers program has played a
pivotal role in providing access to health care for people who are
uninsured or who face other barriers to receiving needed care. When HRSA
makes decisions about awarding program funds to support additional health
center delivery sites, it is faced with the challenge of identifying
applicants that will serve communities with a demonstrated need for
services and that will operate centers that can effectively meet those
needs and remain financially viable. HRSA has indicated that it is not
confident that its award process for new access point grants-which is
intended to meet this challenge-has sufficiently targeted communities with
the greatest need. HRSA's recent effort to evaluate the assessment and
relative weight of need in the award process could result in greater
confidence that the agency is appropriately considering community need in
distributing federal resources to increase access to health care.

In light of the growing federal investment in health centers during the
President's Health Centers Initiative, it is important for HRSA to ensure
that health centers are operating effectively and improving patient health
outcomes. HRSA's adoption of a performance monitoring process that
includes emphasis on patient health outcomes and its efforts to collect
health outcome data constitute an important step in improving the agency's
capacity to assess health centers and the health centers program.
Continued attention to such efforts could improve HRSA's ability to
evaluate its success in improving the health of people in underserved
communities.

It is also important for HRSA to ensure that it is collecting and
reporting accurate and complete information about the number and location
of

delivery sites where health centers are providing care. In providing new
UDS guidance to grantees, HRSA has taken a step toward improving the
quality of its information on delivery sites. The agency will need to
carefully assess the effectiveness of its new guidance and, if necessary,
take additional steps to ensure that delivery site information is
accurate. HRSA officials and the Congress need accurate and complete
information on delivery sites to assess whether the health centers program
is achieving its goal of expanding access to health care for underserved
populations and to make decisions about managing and funding the program.

Recommendation for 	We recommend that, to provide federal policymakers and
program managers with accurate and complete information on the
Consolidated

Executive Action	Health Centers program's activities and progress toward
its performance goals, the Administrator of HRSA ensure that the agency
collects reliable information from grantees on the number and location of
delivery sites funded by the program and accurately reports this
information to the Congress.

Agency Comments	We provided a draft of this report to HRSA for comment.
HRSA acknowledged that more accurate and timely delivery site data would
allow for improved management of the Consolidated Health Centers program
and said that the agency already has efforts under way to increase the
accuracy of delivery site data. (HRSA's comments are reprinted in app. V.)
HRSA stated that the accuracy of delivery site data does not affect its
ability to assess and report the progress of the President's Health
Centers Initiative because it believes this progress is more appropriately
assessed by the number of new access point and expanded medical capacity
grants HRSA has awarded. While HRSA may choose to assess the progress of
the President's Health Centers Initiative on this basis, it is not
appropriate to equate the number of new access point grants awarded to
health centers with the number of delivery sites where these centers
provide care. HRSA did not indicate whether it plans to revise its method
of counting delivery sites for its future reports to the Congress to
include all delivery sites funded since the President's Health Centers
Initiative began. We continue to believe it is important that HRSA collect
and report accurate data on the number and location of all delivery sites
funded by the program so that agency officials and the Congress will have
the information they need to monitor the program's progress in increasing
access to health care and to make decisions about managing and funding the
program. HRSA also

provided technical comments, and we revised our report to reflect the
comments where appropriate.

As arranged with your office, unless you publicly announce the contents of
this report earlier, we plan no further distribution of it until 30 days
after its issue date. At that time, we will send copies of this report to
the Secretary of Health and Human Services, the Admiistrator of the
Centers for Medicare & Medicaid Services, and other interested parties. We
will also make copies available to others upon request. In addition, the
report will be available at no charge on the GAO Web site at
http://www.gao.gov.

If you or your staff have any questions about this report, please contact
me at (202) 512-7119. Contact points for our Offices of Congressional
Relations and Public Affairs may be found on the last page of this report.
An additional contact and the names of other staff members who made
contributions to this report are listed in appendix VI.

Sincerely yours,

Marjorie Kanof Managing Director, Health Care

Appendix I

Scope and Methodology

To do our work, we obtained Consolidated Health Centers program documents,
pertinent studies, and data from the Department of Health and Human
Services' (HHS) Health Resources and Services Administration (HRSA). We
also conducted structured interviews of officials from 12 health centers
in California, Illinois, Pennsylvania, and Texas. We selected these states
because of their geographic diversity and because they were among the
states with the highest number of health centers. Within each of the four
states, we selected 3 health centers, including at least 1 urban and 1
rural center in each state. To ensure that we could obtain information
about securing specialty care for uninsured patients, we selected only
centers where at least 26 percent of the patients were uninsured in
calendar year 2003; 75 percent of all health centers had a proportion of
uninsured patients of at least 26 percent. For each state we selected, we
also interviewed officials from the state's primary care association.1 We
also reviewed the relevant literature and program statutes and regulations
and interviewed officials from the National Association of Community
Health Centers and the National Association of Free Clinics.

To acquire information on health center funding, we examined Consolidated
Health Centers program funding data by grant award type- new access point,
expanded medical capacity, service expansion, service area competition,
and noncompeting continuation-for fiscal years 2002, 2003, and 2004. In
addition, we reviewed information on grant applications HRSA received
during those 3 years. To describe the geographic distribution of health
centers, we analyzed Uniform Data System (UDS) data on health center
location by zip code and state and other data HRSA provided on centers'
urban/rural status. We assessed the reliability of the data on health
center funding and geographic distribution of health centers by
interviewing agency officials knowledgeable about the data and the systems
that produced them, and we determined that the data were sufficiently
reliable for the purposes of this report.

To determine HRSA's process for assessing the need for services, we
reviewed agency grant announcements, grant applications, and application
guidance documents for the various grant types. We also reviewed the
need-for-assistance worksheet and the need criteria in the new access
point grant application guidance. We interviewed agency officials about
the criteria used to assess the application sections on need for services
and

1Primary care associations are private, nonprofit membership organizations
of health centers and other providers.

Appendix I Scope and Methodology

about HRSA's ongoing consideration of revising the way need is assessed
for new access point grants. In addition, we interviewed health center
officials and officials from national and state associations that work
with health centers about their experiences with the grant process.

To examine HRSA's monitoring of health center performance, we reviewed
agency reports and protocols related to the new monitoring process
conducted by the Office of Performance Review (OPR). We interviewed agency
officials about the development of the new process and the roles played by
different agency branches in monitoring health centers. To obtain
information about health centers' experiences with the new OPR performance
review process, we conducted interviews with officials from health centers
that had completed the process. One of the 12 original health centers we
interviewed had completed the OPR performance review process, and we also
interviewed officials at an additional 6 health centers that were among
the first to complete the process. In addition, we reviewed documents
provided by the health centers, including performance reports and action
plans. We also reviewed reports and documents related to HRSA's ongoing
monitoring, including sample tools used by project officers to monitor
their grantees and schedules of site visits conducted by the project
officers. In addition, we reviewed documents related to HRSA's collection
of health center performance data, including agency guidelines for the
Health Disparities Collaboratives and the application for health center
participation in the Sentinel Centers Network.

To assess HRSA's improvements to UDS, we evaluated the completeness and
quality of 2003 data-the most recent data available at the time we
conducted our review. To evaluate overall completeness, we obtained the
master list of 2003 grantees from HRSA and matched the grantees on this
list with those in the 2003 UDS data file. To evaluate the completeness
and quality of specific data elements in the 2003 UDS data file, we
developed and evaluated edit checks of those data elements. We selected
variables that were identified as problematic in our March 2000 report2
and others that were used in our current analysis. We also independently
conducted selected analyses and compared our findings to corresponding
tables in the 2003 National Rollup Report. For example, using 2003 UDS
data, we duplicated the table on services offered and delivery method in
the

2GAO, Community Health Centers: Adapting to Changing Health Care
Environment Key to Continued Success, GAO/HEHS-00-39 (Washington, D.C.:
Mar. 10, 2000). This report focused only on community and migrant health
centers.

Appendix I Scope and Methodology

National Rollup Report and verified that it matched the data HRSA
reported. We did not perform edit checks on the delivery site data
grantees reported to UDS. We interviewed agency officials about how HRSA
collected UDS data on health center delivery sites and determined that the
data were not sufficiently reliable for purposes of our report.

We conducted our work from August 2004 through June 2005 in accordance
with generally accepted government auditing standards.

Appendix II

HRSA's Process for Awarding Grants through the Consolidated Health Centers
Program

HRSA's process for awarding grants through the Consolidated Health Centers
program involves several steps. HRSA provides initial grant information
for new access point, expanded medical capacity, service expansion, and
service area competition grants through the HRSA Preview, a notice
available on HRSA's Web site.1 The preview includes information on
eligibility requirements; the estimated number of awards to be made; the
estimated amount of each award; and the dates that application guidance
will be available, applications will be due, and awards will be made. HRSA
later issues grant application guidance, which includes the forms
applicants need to submit (such as forms describing the composition of the
applicant's governing board, summarizing the funding request, and
describing the type of services to be provided) and a detailed description
of the application review criteria and process.

The application guidance for new access point grants also encourages
applicants to submit a letter of interest prior to submitting a grant
application. In the letter of interest, the applicant describes its
community's need for services and proposes services that the health center
would offer to address those needs. HRSA officials told us that in fiscal
year 2004, nearly one-half of applicants for new access point grants
submitted a letter of interest. HRSA provides feedback to organizations on
whether the proposal is consistent with the objectives of the health
center program and whether HRSA thinks the organization is ready to
establish a new delivery site.

HRSA also provides applicants with technical assistance resources during
the development of grant applications. For example, through cooperative
agreements with HRSA, state primary care associations and the National
Association of Community Health Centers offer regional training sessions
on various topics, including strategic planning, proposal writing,
community assessment, and data collection. Potential applicants may also
contact their state primary care association for individual technical
assistance and application review.

1The 2005 HRSA preview is available on HRSA's Web site at
http://www.hrsa.gov/grants/preview/.

Appendix II HRSA's Process for Awarding Grants through the Consolidated
Health Centers Program

HRSA approves funding for a specific project period-up to 5 years for
existing grantees and up to 3 years for new grantees. HRSA provides funds
for the first year of the project; for subsequent years, health centers
must obtain funding annually through a noncompeting continuation grant
application process in which the grantee must demonstrate that it has made
satisfactory progress in providing services. A grantee's continued receipt
of funds also depends on the availability of funding.

Applications submitted to HRSA go through several stages of review. HRSA
initially screens applications for eligibility based on specific
criteria-the applicant must be a public or private nonprofit entity, the
applicant must be applying for an appropriate grant (e.g., expanded
medical capacity and service expansion grants are available only to
existing grantees), and the application must include the correct documents
and comply with page limitations and format requirements.

Eligible applications go through a review process in which independent
reviewers evaluate and score applications. The reviewers are selected by
HRSA and have expertise in a specific field relevant to the health center
program. HRSA provides reviewers with the same application guidance that
it provides to applicants, and reviewers are to use their professional
judgment in scoring applications.

During the first stage of the review process, HRSA forwards eligible
applications to three independent reviewers, who have 3 to 4 weeks to
individually evaluate the applications. Applications for new access point
grants include a need-for-assistance worksheet, which is evaluated by the
reviewers. HRSA uses the need-for-assistance worksheet to measure barriers
to obtaining care and to measure health disparity factors in the
applicant's proposed service area.2 Applicants can score up to 100 points
on the worksheet, and only those applicants that receive a score of 70 or
higher on the worksheet go on to have the technical merits of their
application evaluated. The reviewers evaluate the merits of all qualified

2Measures of barriers to care include the distance or time to the nearest
primary care provider and percentage of the population age 5 years or
older who speak a language other than English. Health disparity factors
include the rates of specific diseases and health outcomes, such as
cancer, infant mortality, low-birth-weight infants, and teen pregnancy.

Appendix II HRSA's Process for Awarding Grants through the Consolidated
Health Centers Program

applications; they base their review on a standard set of criteria (see
table

2) and give each application a preliminary score of up to 100 points. For
example, reviewers of new access point grant applications evaluate the
need for services through the criterion that describes the applicant's
service area/community and target population and assign a score from 0 to
10, which constitutes a maximum of 10 percent of the applicant's maximum
final score. Similarly, reviewers evaluate the applicant's service
delivery strategy and model and assign a score from 0 to 20, which
constitutes a maximum of 20 percent of the maximum final score.

 Appendix II HRSA's Process for Awarding Grants through the Consolidated Health
                                Centers Program

Table 2: Review Criteria for New Access Point, Expanded Medical Capacity,
Service Expansion, and Service Area Competition Grants, Fiscal Year 2004

Maximum Grant Criteria points

New Access Point Service delivery strategy and model

Health care services

Organizational capabilities and expertise

Budget

Description of the service area/community and target population

Governance

Readinessa

Strategic planning

Expanded Medical Capacity Need

Responseb

Evaluative measuresc

Resources/capabilities

Support requestedd

Impact

Service Expansion Responseb 60 (mental health/substance abuse and oral
Evaluative measuresc 10health services)

Need 10

Resources/capabilities

                                                                     Impact 5
                                                         Support requestedd 5
        Service Area Competition Organizational capabilities and expertise 25
                                       Service delivery strategy and model 20
                                                      Health care services 15
                                                                    Budget 10
           Description of the service area/community and target population 10
                                                                Governance 10
                                                        Strategic planning 10

Source: HRSA's fiscal year 2004 application guidance for new access point,
expanded medical capacity, service expansion, and service area competition
grants.

aThe readiness criterion refers to an applicant's readiness to begin
providing services.

bThe response criterion refers to an applicant's description of its
service delivery and business plans.

cThe evaluative measures criterion refers to how the applicant plans to
measure the success of its program.

dThe support requested criterion refers to an applicant's proposed budget.

Appendix II HRSA's Process for Awarding Grants through the Consolidated
Health Centers Program

During the second stage of the review process, reviewers present the
strengths and weaknesses of the application to a panel of 10 to 15
reviewers. After discussing the application, each panel member scores it.
For each application, HRSA averages the scores assigned by each reviewer
in the panel. The volume of applications may result in HRSA's using
multiple review panels during a funding cycle. When this occurs, HRSA uses
a statistical method to adjust for variation in scores among different
review panels. The adjusted score becomes the final application score, and
the final scores are used to develop a rank order list of applicants.

HRSA bases its award decisions on the rank order of scores and other
factors. Two types of factors-the funding preference and awarding
factors-can affect which applicants HRSA chooses for funding from the rank
order list. The funding preference is given to applicants proposing to
serve a sparsely populated rural area.3 To be considered for the
preference, the applicant must demonstrate that the entire area proposed
to be served by the delivery site has seven or fewer people per square
mile. In addition to scoring an application, the review panel evaluates
the requested funding amount and determines if an applicant should be
considered for the funding preference. The funding preference does not
affect the score, but may place an applicant in a more competitive
position in relation to other applicants. For example, if the panel has
determined that the applicant qualifies for the funding preference, it may
receive a grant award over higher scoring applicants that did not qualify
for the preference. In fiscal year 2004, of the five applicants that
received a service expansion grant to provide new oral health services,
three were determined to qualify for the funding preference. These three
applicants-with scores of 83, 86, and 90- were each awarded a grant over
six applicants with application scores above 90.

As with the funding preference factor, the law requires HRSA to consider
awarding factors in selecting applicants to fund from the rank order list.
HRSA must consider the urban/rural distribution of awards, the
distribution of funds across types of health centers (community, homeless,
migrant, and public housing), and a health center's compliance with

342 U.S.C. S: 254b(p).

Appendix II HRSA's Process for Awarding Grants through the Consolidated
Health Centers Program

program requirements.4 In fiscal year 2004, HRSA gave priority to funding
homeless and migrant health centers and, from the new access point
applications the agency received that year, it funded only health centers
requesting homeless or migrant health center funding.5 HRSA officials said
the agency did this because the applications it had already approved in
fiscal year 2003 for funding in fiscal year 2004, pending funding
availability, did not include applications for homeless or migrant health
center funding. In addition to the preference and awarding factors
specified in the law, HRSA also considers the geographic distribution of
awards in making funding decisions.

HRSA sends a Notice of Grant Award to successful applicants. The notice
includes a set of standard terms and conditions with which the grantee
must comply to receive grant funds, such as allowable uses of federal
funds and reporting requirements. In addition, the notice may include
granteespecific conditions of award. For example, common conditions placed
on new access point awards relate to the health center's being operational
within 120 days, having the appropriate governing board composition, and
hiring key staff. About 80 percent of new access point awards receive at
least one condition, according to HRSA officials. HRSA notifies
unsuccessful applicants of the outcome of the review process and provides
applicants with their score and a summary of their application's strengths
and weaknesses.

4The law requires new access point and service expansion grants to be
awarded so that the population expected to be treated at centers receiving
these grants is 40 to 60 percent rural. 42 U.S.C. S: 254b(k)(4). The law
also requires awards to be made so as to maintain funding levels for the
three types of centers serving special populations (homeless, migrant, and
residents of public housing) at the same proportions that existed in
fiscal year 2001. 42 U.S.C. S: 254b(r)(2)(B).

5Of the applications received in fiscal year 2004, HRSA approved other
types of health centers for funding in fiscal year 2005, pending funding
availability.

Appendix III

Distribution of Consolidated Health Centers Program New Access Point Grants,
Fiscal Years 2002 through 2004

                                    Fiscal year Fiscal year Fiscal year 
                    State/territory        2002        2003    2004     Total 
                            Alabama           1           0           2 
                             Alaska          15           5           0 
                     American Samoa           1           0           0 
                            Arizona           2           4           1 
                           Arkansas           3           1           0 
                         California          29          19           9 
                           Colorado           4           1           0 
                        Connecticut           2           0           0 
                           Delaware           1           0           0 
               District of Columbia           1           0           0 
                Federated States of           0           0           0 
                         Micronesia                                     
                            Florida           4           2           1 
                            Georgia           4           1           2 
                               Guam           0           0           0 
                             Hawaii           1           0           2 
                              Idaho           2           0           1 
                           Illinois           8           3           5    16 
                            Indiana           1           2           3     6 
                               Iowa           2           0           0     2 
                             Kansas           0           1           0     1 
                           Kentucky           2           1           0     3 
                          Louisiana           1           1           3     5 
                              Maine           0           0           3     3 
                   Marshall Islands           0           0           0     0 
                           Maryland           3           2           1     6 
                      Massachusetts           5           1           2     8 
                           Michigan           3           2           1     6 
                          Minnesota           1           1           0     2 
                        Mississippi           1           1           0     2 
                           Missouri           4           0           2     6 
                            Montana           2           3           0     5 
                           Nebraska           0           2           0     2 
                             Nevada           1           1           0     2 
                      New Hampshire           2           0           1     3 

Appendix III Distribution of Consolidated Health Centers Program New
Access Point Grants, Fiscal Years 2002 through 2004

(Continued From Previous Page)

                                Fiscal year Fiscal year Fiscal year 
            State/territory                          2002 2003 2004     Total 
                 New Jersey                                   3 2 0 
                 New Mexico                                   4 3 1 
                   New York                                   9 6 2 
             North Carolina                                   2 4 1 
               North Dakota                                   1 3 0 
                       Ohio                                   2 0 2 
                   Oklahoma                                   3 1 1 
                     Oregon                                   5 6 3 
                      Palau                                   0 0 0 
               Pennsylvania                                   2 0 3 
                Puerto Rico                                   2 1 0 
               Rhode Island                                   0 2 2 
             South Carolina                                   7 2 0 
               South Dakota                                   3 1 0 
                  Tennessee                                   2 3 0 
                      Texas                                   5 2 5 
                       Utah                                   1 2 0         3 
                    Vermont                                   2 0 0         2 
             Virgin Islands                                   1 0 0         1 
                   Virginia                                   4 3 2         9 
                 Washington                                   2 1 2         5 
              West Virginia                                   3 3 0         6 
                  Wisconsin                                   2 0 0         2 
                    Wyoming                                   0 1 0         1 
                      Total                              171 100 63       334 

Appendix IV

Distribution of Consolidated Health Centers Program Grantees, 2001 and 2003

State/territory 2001

Alabama 15

Alaska 6

American Samoa 0

Arizona 13

Arkansas 9

California 57

Colorado 14

Connecticut 9

Delaware 3

District of Columbia 1

Federated States of Micronesia 1

Florida 30

Georgia 20

Guam 1

Hawaii 8

Idaho 6

                 Illinois                             25                31 
                 Indiana                               8                11 
                   Iowa                                7                 8 
                  Kansas                               7                 8 
                 Kentucky                             11                12 
                Louisiana                             15                16 
                  Maine                               12                12 
             Marshall Islands                          1                 1 
                 Maryland                             11                13 
              Massachusetts                           28                33 
                 Michigan                             24                26 
                Minnesota                             10                12 
               Mississippi                            21                21 
                 Missouri                             14                17 
                 Montana                               7                11 
                 Nebraska                              3                 5 
                  Nevada                               2                 2 
              New Hampshire                            5                 7 
                New Jersey                            13                16 

Appendix IV Distribution of Consolidated Health Centers Program Grantees,
2001 and 2003

(Continued From Previous Page)

                       State/territory                2001               2003 
                            New Mexico                  12                 14 
                              New York                  44 
                        North Carolina                  21 
                          North Dakota                   1 
                                  Ohio                  19 
                              Oklahoma                   4 
                                Oregon                  11 
                                 Palau                   1 
                          Pennsylvania                  27 
                           Puerto Rico                  20 
                          Rhode Island                   5 
                        South Carolina                  19 
                          South Dakota                   6 
                             Tennessee                  19 
                                 Texas                  31 
                                  Utah                   9 

                Vermont                               2                  3 
             Virgin Islands                           2                  2 
                Virginia                             18                 18 
               Washington                            21                 22 
             West Virginia                           22                 27 
               Wisconsin                             13                 14 
                Wyoming                               4                  4 
                 Total                              748                890 

Source: HRSA's UDS, Calendar Year 2001 Data: National Rollup Report,
Rollup Summary and Calendar Year 2003 Data: National Rollup Report, Rollup
Summary.

Note: Table includes the 748 and 890 grantees that submitted data to the
2001 and 2003 UDS, respectively. The 2001 data provide the number of
grantees operating before the President's Health Centers Initiative began
and the 2003 data were the most recent data available at the time we
conducted our review.

Appendix V

Comments from the Health Resources and Services Administration

Appendix V
Comments from the Health Resources and
Services Administration

Appendix VI

                     GAO Contact and Staff Acknowledgments	

                   GAO Contact Helene F. Toiv, (202) 512-7162

Acknowledgments
In addition to the person named above, key contributors to this report
were Donna Almario, Janina Austin, Anne McDermott, Julie Thomas, Roseanne
Price, and Daniel Ries.

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