Health Professional Shortage Areas: Problems Remain with Primary 
Care Shortage Area Designation System (24-OCT-06, GAO-07-84).	 
                                                                 
To identify areas facing shortages of health care providers, the 
Department of Health and Human Services (HHS) relies on its	 
health professional shortage area (HPSA) designation system. HHS 
designates geographic, population-group, and facility HPSAs. HHS 
also gives each HPSA a score to rank its need for providers	 
relative to other HPSAs. The Health Care Safety Net Amendments of
2002 required GAO to report on the HPSA designation system. GAO  
reviewed (1) the number and location of HPSAs and federal	 
programs that use HPSA designations to allocate resources or	 
provide benefits, (2) available research on HPSA designation	 
criteria and methodology, and (3) the impact of a 2002 provision 
that automatically designates federally qualified health centers 
and certain rural health clinics as facility HPSAs. GAO obtained 
and analyzed HHS's data on primary care HPSA designations as of  
September 2005 and January 2006 and identified reports on HPSA	 
criteria and methodology through a literature search of 	 
peer-reviewed journals and other reports published since 1995.	 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-07-84						        
    ACCNO:   A62446						        
  TITLE:     Health Professional Shortage Areas: Problems Remain with 
Primary Care Shortage Area Designation System			 
     DATE:   10/24/2006 
  SUBJECT:   Allocation (Government accounting) 		 
	     Eligibility criteria				 
	     Health care facilities				 
	     Health care personnel				 
	     Health care programs				 
	     Health care services				 
	     Health statistics					 
	     Labor shortages					 
	     Population statistics				 
	     Program evaluation 				 
	     HHS Health Professional Shortage Area		 
	     System						 
                                                                 

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GAO-07-84

     

     * Results in Brief
     * Background
     * HPSAs Are Located in Every State and Are Used by Multiple Fe
          * Number and Location of HPSAs
          * Federal Programs Using HPSA Designations
     * Research Points to Shortcomings with Designation Methodology
     * Many Health Centers and Rural Health Clinics Did Not Benefit
          * Relatively Few Health Centers Had HPSA Scores High Enough to
          * Few Rural Health Clinics Have Received Automatic HPSA Design
     * Conclusions
     * Recommendations for Executive Action
     * Agency Comments
     * GAO Contact
     * Acknowledgments
     * GAO's Mission
     * Obtaining Copies of GAO Reports and Testimony
          * Order by Mail or Phone
     * To Report Fraud, Waste, and Abuse in Federal Programs
     * Congressional Relations
     * Public Affairs

Report to Congressional Committees

United States Government Accountability Office

GAO

October 2006

HEALTH PROFESSIONAL SHORTAGE AREAS

Problems Remain with Primary Care Shortage Area Designation System

GAO-07-84

Contents

Letter 1

Results in Brief 5
Background 8
HPSAs Are Located in Every State and Are Used by Multiple Federal Programs
14
Research Points to Shortcomings with Designation Methodology 25
Many Health Centers and Rural Health Clinics Did Not Benefit from
Automatic HPSA Designation 29
Conclusions 34
Recommendations for Executive Action 35
Agency Comments 35
Appendix I Scoring of Health Professional Shortage Areas 38
Appendix II Medically Underserved Area or Population Designations and
Medically Underserved Community Definition 41
Appendix III Scope and Methodology 45
Appendix IV Federal Programs Using Health Professional Shortage Area and
Other Designations of Underservice 49
Appendix V Comments from the Department of Health and Human Services 55
Appendix VI GAO Contact and Staff Acknowledgments 59
Related GAO Products 60

Tables

Table 1: Number of, Population in, and Physicians Needed in Geographic and
Population-Group HPSAs, September 2005 15
Table 2: Programs and Administering Agencies That Used HPSA, MUA, MUP or
Other Designations to Allocate Resources or Provide Benefits in Fiscal
Year 2005 49

Figures

Figure 1: HPSA Designation Request and Review Process, 2005 9
Figure 2: Types of HPSAs and Criteria Used to Designate Them, 2005 10
Figure 3: U.S. Counties with Geographic and Population-Group HPSAs,
January 2006 16
Figure 4: Types of Facility HPSAs, September 2005 19
Figure 5: Distribution of HPSA Scores among Health Centers Automatically
Designated as Facility HPSAs, September 2005 31
Figure 6: Distribution of HPSA Scores among Rural Health Clinics
Automatically Designated as Facility HPSAs, September 2005 34
Figure 7: Scoring of HPSAs, 2005 39

Abbreviations

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

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United States Government Accountability Office

Washington, DC 20548

October 24, 2006

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

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

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

Many Americans live in areas, such as inner-city neighborhoods or isolated
rural locations, where obtaining health care is difficult because health
care providers are in short supply. To identify areas facing a critical
shortage of providers, the Department of Health and Human Services (HHS)
relies on its health professional shortage area (HPSA) designation
system.1 Originally created in 1978 to identify areas in need of
physicians and other health care providers from HHS's National Health
Service Corps (NHSC) programs, HPSA designation is now used by a variety
of federal programs-including programs that provide grants for health
professions education and training or bonus payments under Medicare for
physician services-to allocate resources or provide benefits.2

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

A HPSA can be a distinct geographic area (such as a county), a specific
population group within an area (such as low-income individuals), or a
specific health care facility. Facility HPSAs include federal or state
correctional institutions, as well as federally qualified health
centers-facilities that provide primary care services in underserved
areas3-and certain rural health clinics-facilities that provide outpatient
primary care services in rural areas.4 HHS's Health Resources and Services
Administration (HRSA)-the HHS agency that manages the HPSA designation
system-designates HPSAs based on the ratio of population to the number of
primary care physicians and other factors.5 HRSA then assigns each HPSA a
score on the basis of specific criteria that ranks its shortage of primary
care providers, or need, relative to other HPSAs.6 Some federal health
care programs, such as NHSC programs, allocate their resources on the
basis of HPSA scores, not just HPSA designations.

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

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

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

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

HHS's criteria and methodology for designating HPSAs has remained
unchanged since October 1, 1993.7 In 1998, in an effort to improve the way
underserved areas were designated, HHS published a proposal to revise the
HPSA designation system.8 The department received more than 800 comments
on its proposal from individuals and organizations, including individual
physicians, state primary care organizations, and university or research
organizations. These comments raised several issues, such as whether or
how to count nonphysician providers, such as physician assistants, in the
total number of practitioners serving a population; the potential number
of HPSAs that would lose their HPSA designations because of changes in the
designation criteria; and the incorporation of certain population factors,
such as the percentage of elderly and uninsured individuals, which reflect
a population's ability to access care. In response to these comments, HHS
withdrew its 1998 proposal, and left the existing HPSA designation system
in place while it began working on another proposal.

The Health Care Safety Net Amendments of 2002 required that we report on
the HPSA designation system and on a provision included in the act that
automatically designates health centers and certain rural health clinics
as facility HPSAs.9 As discussed with the committees of jurisdiction, this
report discusses (1) the number and location of HPSAs and the federal
programs that use HPSA designations to allocate resources or provide
benefits, (2) available research on the criteria and methodology used to
designate HPSAs, and (3) the impact of the automatic HPSA designation on
health centers and rural health clinics.

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

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

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

To conduct our work, we examined relevant laws, regulations, and HHS
documents related to the HPSA criteria in effect in 2005-criteria that had
remained unchanged since 1993-and reviewed our prior work on the HPSA
designation system. To determine the number of HPSAs, we interviewed
officials from HRSA, who reported that precise, accurate, historical data
on the total number of HPSAs were not available. Therefore, to estimate
the number of HPSAs designated as of September 2005, we designed a
methodology that used data from HRSA, including summary statistics on
geographic and population-group HPSA designations and data files on the
facilities that were automatically designated as HPSAs. We also analyzed a
more detailed database of geographic and population-group HPSAs as of
January 2006 in order to identify (1) the counties in which geographic and
population-group HPSAs were located and (2) the HPSAs that were proposed
for having their designations withdrawn because they no longer met the
criteria or did not provide updated data in support of their designations.
After taking steps to eliminate potential duplications or inconsistencies
in the data we used, we determined that the data were sufficiently
reliable for our purposes. To obtain information on HPSA designations and
federal programs that use HPSA designations, we reviewed Federal Register
notices and other documents obtained from HHS agencies-including HRSA, the
Centers for Medicare & Medicaid Services (CMS), and the Indian Health
Service (IHS)-and reviewed our prior work on these programs.

To identify available research on the criteria and methodology used to
designate HPSAs, we conducted a literature search of reports, including
those published in peer-reviewed journals, issued from January 1, 1995,
through November 1, 2005. We identified other published reports discussing
the HPSA designation methodology, including one by the Council on Graduate
Medical Education (COGME). Of the more than 340 articles, studies, and
reports-which we refer to as reports-identified in the search, we
identified 7 that addressed the relationship between key elements of the
HPSA designation criteria, such as income, and primary care physician
supply or shortages, or that addressed factors related to the HPSA
designation methodology. We also interviewed researchers who have studied
primary care provider shortages, as well as HRSA officials knowledgeable
about the HPSA designation system. To review the impact of the automatic
designation on health centers and rural health clinics, we analyzed HRSA's
data on automatic HPSA designations, including the HPSA scores associated
with automatic designation, and interviewed HRSA officials and officials
from associations representing these types of facilities. We performed our
work from August 2005 through September 2006 in accordance with generally
accepted government auditing standards.10

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

                                Results in Brief

We identified more than 5,500 HPSAs designated throughout the United
States as of September 2005; multiple federal programs relied on these
designations to allocate resources or provide benefits. We estimated that
slightly more than half of the HPSAs were designated for geographic areas
or population groups, and these geographic and population-group HPSAs were
located in all 50 states and the District of Columbia. Facility HPSAs,
which accounted for slightly less than half of the total number of HPSAs,
were also located in every state and the District of Columbia. In fiscal
year 2005, more than 30 federal programs-including programs administered
by HRSA, CMS, and federal agencies outside of HHS-relied on HPSA
designations and, in some cases, HPSA scores, to allocate resources or
provide benefits. These included NHSC programs that award scholarships or
educational loan repayment to students and health professionals in
exchange for a commitment to practice in HPSAs for at least 2 years. Other
programs relying on HPSA designations to allocate resources or provide
benefits included programs that pay physicians bonus payments for services
provided to Medicare beneficiaries in geographic HPSAs and programs that
waive certain requirements for foreign physicians if they agree to
practice in HPSAs or other underserved areas of the United States. The use
of the HPSA designation by numerous federal programs to allocate resources
or provide benefits is an incentive for obtaining and retaining a HPSA
designation.

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

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

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

We are recommending that HHS (1) publish a list of designated HPSAs in the
Federal Register or otherwise remove, through Federal Register
notification, the HPSA designations for those HPSAs that no longer meet
the criteria or have not provided updated data demonstrating they still
meet the designation criteria and (2) complete and publish HHS's proposal
to revise the HPSA designation system and address the problems that have
been identified in the current methodology for designating HPSAs.

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

                                   Background

Any agency or individual may request a HPSA designation for a geographic
area, population group, or facility.11 According to HRSA officials, the
vast majority of HPSA designation requests are submitted by state primary
care offices.12 These requests are received and reviewed by the Shortage
Designation Branch within HRSA. Individual and agency requesters, other
than state primary care offices, are required to submit a copy of their
request for HPSA designation to their state's primary care office. The
state primary care office solicits comments about the request from state
groups, including the state health department and state professional
associations, and forwards the comments to HRSA. Other interested parties
may also provide comments on the request and submit the comments directly
to HRSA. HRSA's final designation decision is based on a review of the
request and comments received from the state and other interested parties
(see fig. 1).

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

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

Figure 1: HPSA Designation Request and Review Process, 2005

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

HRSA designates three types of HPSAs: geographic, population-group, and
facility. Geographic HPSAs include entire counties, a portion of a county,
or a group of contiguous counties. Population-group HPSAs include groups,
such as migrant farmworkers, low-income urban populations, or federally
recognized Native American Tribes or Alaska Natives, within a particular
geographic area. Facility HPSAs include federal or state correctional
institutions, health centers, and certain rural health clinics. To receive
HPSA designation, the requesting agency or individual must provide HRSA
with information demonstrating that the area, population group, or
facility meets applicable criteria (see fig. 2).13

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

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

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

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

Since 2002, two kinds of facilities-(1) health centers and (2) rural
health clinics that certify that they treat everyone regardless of ability
to pay-have been automatically designated as facility HPSAs without going
through the standard request and review process.14 Health centers include
consolidated health centers, health center look-alikes, and tribal health
centers:15

           o  Consolidated Health Centers: These health centers-which include
           community health centers, migrant health centers, health centers
           for the homeless, and health centers for residents of public
           housing-receive grants and grant funding16 under section 330 of
           the Public Health Service Act. Consolidated health centers provide
           comprehensive community-based primary care services to individuals
           regardless of their ability to pay and are required to serve the
           medically underserved.17

           o  Health center look-alikes: These facilities have been
           determined to meet all of the requirements necessary to receive a
           grant under section 330 of the Public Health Service Act but do
           not receive such funding.
           o  Tribal health centers: These facilities receive federal support
           to provide outpatient health services and are operated by tribes,
           tribal organizations, or urban Indian organizations under the
           Indian Self-Determination Act or the Indian Health Care
           Improvement Act.

           Rural health clinics are located in rural areas and can operate
           either independently or as part of a larger organization, such as
           a hospital, skilled nursing facility, or home health agency.18
           Unlike health centers, which are public or private nonprofit
           facilities, rural health clinics may function as for-profit
           entities. Rural health clinics must offer primarily outpatient
           primary medical care, but unlike health centers, they are not
           required to serve all individuals regardless of their ability to
           pay. Therefore, those rural health clinics that wish to receive
           automatic facility HPSA designation must certify to HRSA that they
           provide services to all individuals, regardless of their ability
           to pay, in order to receive the designation.

           After receiving the HPSA designation, each geographic,
           population-group, and facility HPSA is scored on a scale of 0 to
           25, with higher scores indicating greater relative need for
           primary care providers. The HPSA score is based on four elements,
           including elements used for HPSA designation: the ratio of
           population to primary care physicians (1 to 5 possible points,
           then doubled), poverty rate (0 to 5 possible points), infant
           mortality rate or low birth weight rate (0 to 5 possible points),
           and travel time or distance to the nearest available source of
           primary care (0 to 5 possible points). For a health center or
           rural health clinic automatically designated as a facility HPSA,
           if complete data are not available or HRSA cannot match the
           facility to appropriate data to calculate a HPSA score, the HPSA
           receives either a score of 0 or a partial score based on the sum
           of factors for which data are obtainable.19 According to HRSA's
           data on health centers and rural health clinics that received
           automatic designation as facility HPSAs, 10 percent of these
           facility HPSAs had a HPSA score of 0 as of September 2005.

           HRSA calculates the HPSA score using the information from the HPSA
           designation request. For health centers and rural health clinics
           that receive automatic facility HPSA designation, HRSA calculates
           the HPSA score using nationally available data and approximates
           the service area of a health center or rural health clinic by
           using data on the Primary Care Service Area in which the facility
           is located.20 Any automatically designated facility HPSA located
           in a geographic or population-group HPSA may instead use the HPSA
           score for that geographic area or population group, which,
           according to HRSA officials, is likely to be much higher than the
           automatic facility HPSA score.21 According to HRSA officials,
           nationally available data used for automatic facility HPSA scores
           are often not as current or as precise as data collected for
           individual geographic and population-group HPSA designations.

           HHS is required by law to review HPSA designations annually to
           determine if the designations remain appropriate in light of the
           applicable requirements.22 Each year, it must also publish a list
           of designated HPSAs in the Federal Register.23 For HPSAs
           designated through the standard request and review process, HHS
           reviews the designations by giving a list of HPSAs that have been
           designated for 3 full years to each state and asking the relevant
           state groups-including the state's governor's office and state
           health department-to update the information. HPSA designations for
           which data are not provided or that no longer meet the designation
           criteria are proposed for withdrawal. A HPSA that is proposed for
           withdrawal remains designated as a HPSA until HHS publishes in the
           Federal Register either a notification that the HPSA designation
           has been withdrawn or an updated list of designated HPSAs that
           does not include that HPSA.24 Before a HPSA designation can be
           withdrawn, however, interested parties and groups must be allowed
           to provide data and information in support of the designation. A
           health center or rural health clinic receiving automatic facility
           HPSA designation must demonstrate every 6 years after receiving
           its automatic designation that it meets the definition of a
           HPSA.25

           HPSAs Are Located in Every State and Are Used by Multiple Federal
			  Programs
			  
			  More than 5,500 HPSAs were located throughout the country as of
           September 2005. We estimated that over half of these HPSAs were
           geographic or population-group HPSAs; the rest were facility
           HPSAs. Numerous federal programs have used these HPSA designations
           to allocate their programs' resources or provide benefits, which
           is an incentive for obtaining and retaining the HPSA designation.

           Number and Location of HPSAs
			  
			  Using HRSA data, we identified 5,594 designated HPSAs as of
           September 2005. We estimated that slightly more than half (3,032)
           of these HPSAs were designated for geographic areas or population
           groups. HRSA calculated that geographic and population-group HPSAs
           needed 6,941 additional full-time primary care physicians to
           achieve ratios of population to primary care physicians that would
           remove the HPSA designations (see table 1).

           Table 1: Number of, Population in, and Physicians Needed in
           Geographic and Population-Group HPSAs, September 2005	  
			  
                         Number of       Population in           Primary care 
HPSA type                 HPSAs              HPSAsa     physicians neededb 
Geographic area           1,646          34,821,125                  3,549 
Population group          1,386          24,912,956                  3,392 
Total                     3,032          59,734,081                  6,941 

           Source: HRSA.

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

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

           Of the 1,646 geographic HPSAs, slightly more than half (831)
           consisted of an entire county, and the remainder (815) consisted
           of other service areas within counties, such as specific census
           tracts. As illustrated in figure 3, geographic and
           population-group HPSAs designated as of January 2006 were located
           in 2,494 counties in all 50 states and the District of Columbia.26

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

1442 U.S.C. S:S: 254e(a)(1), 254g(a)(1), 1395x(aa)(2), (4).

15Health centers are reimbursed under CMS's Medicare and Medicaid programs
using special payment mechanisms that serve as an incentive for becoming a
health center. See also GAO, Health Centers and Rural Clinics: State and
Federal Implementation Issues for Medicaid's New Payment System,
GAO-05-452 (Washington, D.C.: June 17, 2005).

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

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

18Rural health clinics are reimbursed under CMS's Medicare and Medicaid
programs using special payment mechanisms that serve as an incentive for
becoming a rural health clinic. To be reimbursed under Medicare and
Medicaid, a rural health clinic must be located in a geographic or
population-group HPSA in a rural area, a rural area designated by a
state's governor (or chief executive officer) and certified by HHS as an
area with a shortage of personal health services, or a rural area HRSA has
designated as an MUA. See appendix II for additional information on the
MUA designation.

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

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

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

2242 U.S.C. S: 254e(d)(1); 42 C.F.R. S: 5.4(b) (2005).

2342 U.S.C. S: 254e(d)(2).

2442 C.F.R. S: 5.4(d) (2005).

2542 U.S.C. S: 254e(a)(1).

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

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

We estimated that slightly less than half (2,562) of all HPSAs designated
as of September 2005 were facility HPSAs. Of these, about 63 percent
(1,625) were health centers,27 about 23 percent (590) were rural health
clinics, and about 14 percent (347) were federal or state correctional
institutions (see fig. 4). Excluded from this count of facility HPSAs were
136 public or nonprofit medical facilities that HRSA's data indicated had
requested and received a facility HPSA designation, but that HRSA
officials said could be duplicates of health centers that HRSA's data
showed as having automatically received a facility HPSA designation. Also
excluded were 21 health centers that HRSA's data identified as health
centers for Alaska Natives that received automatic facility HPSA
designations, but that HRSA and IHS officials said could be duplicates of
health centers HRSA's data identified as tribal health centers.

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

Figure 4: Types of Facility HPSAs, September 2005

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

As of September 2005, health centers with facility HPSA designations were
located in all 50 states and the District of Columbia.28 Rural health
clinics with facility HPSA designations were located in 41 states, and
federal or state correctional institutions with facility HPSA designations
were located in 46 states.29

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

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

Federal Programs Using HPSA Designations

Although the HPSA designation system was originally used to designate
areas for placement of providers through NHSC programs, the HPSA
designation, and in some cases the HPSA score, have since been used by
more than 30 federal programs to allocate resources or provide benefits.
In fiscal year 2005, NHSC-which received $131 million in funding from HRSA
appropriations-administered four programs that used the HPSA
designation-three of which also used the HPSA score:30

           o  NHSC Scholarship Program: NHSC awards scholarships to health
           professions students who agree to practice for at least 2 years in
           a HPSA after completing training as a primary care physician,
           nurse practitioner, nurse-midwife, physician assistant, or other
           eligible provider.31 Scholarship recipients are limited to
           practicing at NHSC-approved practice sites in HPSAs with high
           need, as determined by the HPSA designation score.32 For the
           period July 1, 2005, through June 30, 2006, scholarship recipients
           completing training who were primary care physicians were required
           to practice in HPSAs with scores of 14 or higher, while those
           completing training as nurse practitioners, physician assistants,
           and nurse-midwives were required to practice in HPSAs with scores
           of at least 13, 13, and 8, respectively.33 At the end of fiscal
           year 2005, about 670 NHSC scholarship recipients, including
           primary care physicians, nurse practitioners, nurse-midwives, and
           physician assistants, were practicing in HPSAs to complete their
           NHSC service obligations.34

           o  NHSC Loan Repayment Program: NHSC repays educational loans of
           fully trained health professionals who agree to practice for at
           least 2 years in a HPSA.35 In addition to the practice sites
           approved for scholarship recipients, loan repayment
           recipients-including primary care physicians, nurse practitioners,
           physician assistants, nurse-midwives, and other providers-may
           practice at NHSC-approved sites in other HPSAs, including those
           with lower HPSA scores. Loan repayment awards are made to
           providers who practice in higher-scoring HPSAs first, and then to
           providers who practice in lower-scoring HPSAs in descending order
           as long as program funds are available. Sufficient funds were
           available for fiscal years 2003 through 2005 to make awards to all
           providers with eligible and complete loan repayment applications,
           regardless of the practice location's HPSA score. At the end of
           fiscal year 2005, about 1,700 NHSC loan repayment recipients were
           practicing in HPSAs to complete their NHSC service obligations.

           o  NHSC State Loan Repayment Program: NHSC provides grants to
           states to operate state loan repayment programs.36 Eligibility
           requirements and benefits, such as the maximum amount of loan
           repayment each year, may vary from state to state, but state loan
           repayment recipients must agree to provide primary health services
           in a HPSA. At the end of fiscal year 2005, about 680 NHSC state
           loan repayment recipients were practicing in HPSAs under this
           program.

           o  NHSC Ready Responder Program: Providers-including primary care
           physicians, nurse practitioners, physician assistants, and
           nurses-can receive salaries, benefits, and moving expenses to
           serve as commissioned officers in the U.S. Public Health Service
           who are assigned by NHSC to practice for 3 years in the neediest
           HPSAs.37 In determining practice locations for Ready Responders,
           NHSC gives preference to NHSC-approved sites in HPSAs with high
           scores. HRSA's 2004 notice to recruit providers to participate in
           this program stated that NHSC Ready Responders would be part of a
           mobile team of health professionals who, in addition to the
           services they provide to patients at their assigned sites, might
           be called upon to respond to regional or national emergencies. At
           the end of fiscal year 2005, 56 NHSC Ready Responders were
           practicing in HPSAs.

           In addition to the 4 NHSC programs, more than 26 other federal
           programs have used the HPSA designation to allocate resources or
           provide benefits.38 For example:

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

           o  CMS's Rural Health Clinic program employs special payment rules
           for the reimbursement of services provided by rural health clinics
           under Medicare and Medicaid, which is an incentive for becoming a
           rural health clinic. For example, rural health clinics are
           reimbursed under a modified cost-based method of payment under
           Medicare. For reimbursement purposes, a rural health clinic must
           be located in a geographic or population-group HPSA in a rural
           area, a rural area designated by a state's governor (or chief
           executive officer) and certified by HHS as an area with a shortage
           of personal health services, or a rural area HRSA has designated
           as a medically underserved area (MUA).40

           o  Federal agencies-including HHS, the Appalachian Regional
           Commission,41 and the Delta Regional Authority42-as well as state
           health departments, operate programs, called J-1 visa waiver
           programs, to attract foreign physicians who have just completed
           their graduate medical education in the United States to practice
           in underserved areas. In exchange for a commitment to practice for
           at least 3 years at a facility located in, or treating residents
           of, a HPSA, an MUA, or a medically underserved population (MUP),
           foreign physicians can receive the benefit of a waiver of a 2-year
           foreign residence requirement.43 Of the federal agencies
           administering J-1 visa waiver programs in 2005, HHS required
           foreign physicians receiving J-1 visa waivers through its J-1 visa
           waiver program to practice in certain health centers, rural health
           clinics, or other facilities in HPSAs with a HPSA score of 14 or
           higher.44

           o  More than 15 federal programs that funded health professions
           education and training grants in fiscal year 2005 used the HPSA
           designation to provide funding preferences to grant applicants.45
           Authorized under title VII of the Public Health Service Act-with
           more than $160 million in funding from HRSA's fiscal year 2005
           appropriations-these programs provided funding preferences to
           grant applicants, such as health professions schools that placed a
           high or increasing number of graduates in settings serving
           medically underserved communities, including HPSAs. For purposes
           of the funding preference, the Public Health Service Act defines
           medically underserved communities to include areas or populations
           that are eligible for HPSA designation, or that meet other
           criteria, such as being eligible to be served by a community or
           migrant health center.46

           The use of the HPSA designation by more than 30 federal programs
           to allocate resources or provide benefits is an incentive for
           obtaining and retaining a HPSA designation, even if the HPSA does
           not want or need additional primary care providers. Agencies or
           individuals requesting initial designations or continuations of
           the HPSA designations for geographic areas, population groups, or
           facilities may instead want the designation for other purposes,
           for example, to be eligible for benefits such as the 10 percent
           bonus payment for physician services under CMS's Medicare
           Incentive Payment program. In 1998, COGME reported that one
           possible reason that the number of HPSAs had not declined was that
           "as the penalty for designation loss has increased, organizations
           have become more adept at making the case for retaining or
           attaining this coveted status."47
			  
			  Research Points to Shortcomings with Designation Methodology

           Of the reports published since 1995 that addressed the criteria or
           methodology used to designate HPSAs, we identified one that
           supported one key element of the criteria and six that pointed to
           shortcomings in the designation methodology. These six reports
           were consistent with what we reported in 1995. HHS officials have
           acknowledged these shortcomings and the department has been
           working on a proposal for revising the HPSA designation system
           since 1998, which, as of September 2006, had not been finalized.
           Another problem we identified in 1995 that persists in 2006 is
           HRSA's lack of timely removal of HPSA designations that no longer
           meet the designation criteria.

           Of the seven reports we identified as research on the HPSA
           criteria or methodology, one of the peer-reviewed reports
           addressed the relationship between one key element of the HPSA
           designation criteria and primary care physician supply. This
           report found a positive association between primary care physician
           supply and an area's income-one of the elements of the HPSA
           criteria used to demonstrate unusually high needs for primary care
           services. Specifically, the researchers found that areas with
           higher incomes had a greater number of primary care physicians
           than areas with lower incomes.48

           Other published reports have, however, pointed to shortcomings in
           the methodology HRSA uses to designate HPSAs-specifically that the
           system has not effectively identified areas with primary care
           shortages or helped target federal resources to benefit those who
           are underserved.49 For example, reports-including one we issued in
           1995-have noted that HRSA's designation methodology does not
           accurately identify those providers available to furnish primary
           health care services.50 As a result, the HPSA methodology can
           overstate the need for additional primary care providers, limiting
           the usefulness of the HPSA designation system as a screen to
           identify which communities should be eligible for additional
           program benefits. Since 1995, we and others have reported problems
           with HRSA's exclusion of several categories of primary care
           providers when calculating the available primary care providers.
           For example, in our 1995 report, we estimated that the reported
           need for additional providers in 1994 would have been reduced by
           up to 50 percent if certain categories of primary care physicians
           and nonphysician providers-which were excluded by HRSA-had been
           included in the HPSA calculations.51 In total, we estimated that
           2,539 primary care physicians already providing services in
           shortage areas (including NHSC physicians and foreign physicians
           with J-1 visa waivers) and other categories of providers who
           deliver primary care services in HPSAs (including physician
           assistants and nurse-midwives) were excluded by HRSA in 1994.

           Reports have also concluded that some of the geographic areas that
           HRSA evaluates for designation-that is, those based on county
           boundaries-may not always provide a realistic reflection of an
           area's health care needs. For these HPSA designation requests,
           measuring the availability of primary care physicians only in the
           county where individuals live may underestimate certain residents'
           access to medical care.52 For example, two reports we identified
           discussed the likelihood of people crossing county lines to obtain
           health care services when these services were not available in
           their community.53 In one report, researchers evaluated the
           relationship between health status and medical care resources and
           found that individuals aged 64 years or younger living in
           nonmetropolitan areas reported better health when there was
           greater physician supply in the county where they lived and
           adjoining counties. According to these researchers, the results
           suggested that younger individuals in nonmetropolitan areas were
           willing and able to cross county lines to obtain health care.54

           Researchers have also noted that the HPSA designation methodology
           favors those states or areas that have experience in completing
           and submitting a HPSA designation request.55 One team of
           researchers reported that officials in certain states and
           localities were effective in identifying areas that would qualify
           for a HPSA designation and in providing timely and appropriate
           data for the request, whereas other areas were unable to navigate
           the process as effectively. The researchers observed that certain
           areas were more likely to have HPSA designations than
           others-independent of the actual local situation.56

           Recognizing the shortcomings in the HPSA designation system
           identified by available research and our prior work, HHS has been
           working on a proposal for a revised designation system since 1998.
           According to HRSA officials, the proposal incorporates factors to
           account for all primary care providers in an area-including
           foreign physicians with J-1 visa waivers, NHSC physicians, and
           nurse practitioners and physician assistants-and includes the
           creation of a master database to house national data relevant to
           HPSA criteria. As of September 2006, this proposal was in the
           department's clearance process.

           Another problem we identified in 1995, that remains a problem in
           2006, is that HRSA does not review designated HPSAs and
           subsequently remove the designation of those areas, population
           groups, or facilities that no longer meet the HPSA criteria in a
           timely manner. While we did not audit HRSA's process for
           periodically reviewing HPSAs, in August 2005, the HHS Office of
           Inspector General reported that as of 2003, HRSA had not conducted
           timely reviews of HPSA designations.57 In the agency's comments
           that were included in the August 2005 report, HRSA acknowledged
           this problem, stating that the agency was unable to complete the
           review of designated HPSAs for continued eligibility in less than
           3 years because of resource limitations. As of September 2006, we
           found that although HHS is required to publish a list of
           designated HPSAs in the Federal Register by July 1 of each
           year-thereby removing the designation of any HPSAs that were
           proposed for withdrawal that are not published-the department has
           not done so since February 2002.58 HRSA officials told us in June
           2006 that the department has not published a list of HPSAs in the
           Federal Register for more than 4 years because of difficulties
           with computer programming, but the agency hoped to resolve those
           issues and to forward an updated list for publication by fall
           2006.59 Meanwhile, those HPSAs that were proposed for withdrawal
           because they no longer meet the HPSA criteria have retained their
           HPSA designation.60 As a result, federal programs that use the
           HPSA designation, such as the Medicare Incentive Payment program
           or HRSA's health professions education and training programs, may
           have been allocating resources or providing benefits to areas,
           population groups, or facilities that no longer meet the HPSA
           criteria.
			  
			  Many Health Centers and Rural Health Clinics Did Not Benefit from
			  Automatic HPSA Designation

           Many health centers and rural health clinics did not benefit from
           automatic designation as facility HPSAs because they were located
           in geographic or population-group HPSAs. Most health centers also
           received a HPSA score associated with the automatic designation
           that was too low to qualify them for programs that required a
           minimum HPSA score in 2005, although they qualified for programs
           that did not have such a requirement. Of the relatively few rural
           health clinics that chose to certify that they would treat anyone
           regardless of ability to pay and, as a result, received the
           automatic designation as facility HPSAs, most also received scores
           too low to qualify for benefits from certain programs that
           required a higher HPSA score.
			  
			  Relatively Few Health Centers Had HPSA Scores High Enough to Obtain
			  Providers through Certain Federal Programs

           For health centers that were located in a geographic or
           population-group HPSA, automatic designation as a facility HPSA
           provided no benefit unless the HPSA score associated with
           automatic designation was higher than the score for the geographic
           or population-group HPSA in which they were located. According to
           the National Association of Community Health Centers, health
           centers had advocated for automatic HPSA designation because it
           would allow those not located in geographic or population-group
           HPSAs to be eligible for providers from NHSC. Although limitations
           in HRSA's data prevented us from measuring the precise impact of
           the automatic HPSA designation on health centers, HRSA officials
           estimated that about half of the health centers that received
           automatic designation as a facility HPSA in 2002 were located in a
           geographic or population-group HPSA and therefore did not receive
           this benefit.
			  
			  Few Rural Health Clinics Have Received Automatic HPSA Designation
			  as Facility HPSAs

           As of September 2005, 73 (less than 5 percent) of the 1,625 health
           centers that had received automatic designation as facility HPSAs
           had an associated HPSA score high enough to qualify for a
           physician through the NHSC Scholarship Program or HHS's J-1 visa
           waiver program.61 These health centers received a HPSA score of 14
           or higher-the HPSA score required by these programs for physician
           placement (see fig. 5). Eighty-six (about 5 percent) of the 1,625
           health centers with automatic facility HPSA designation received a
           HPSA score of 13 or higher-the HPSA score required by the NHSC
           Scholarship Program to qualify for placement of a nurse
           practitioner or physician assistant.

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

3142 U.S.C. S: 254l(f)(1)(B)(v). Scholarship recipients receive payment of
tuition and other educational expenses, such as fees and books, as well as
a stipend for up to 4 years of education. For each year of support
received, the recipient is required to serve 1 year in an NHSC-approved
practice site in a high-need HPSA, with a minimum service commitment of 2
years.

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

3370 Fed. Reg. 51356-7 (Aug. 30, 2005). The minimum HPSA score for the
practice sites eligible for NHSC scholarship recipients in a given year
depends on both the practice sites applying for scholarship recipients in
that discipline and the number of scholarship recipients graduating in
each discipline that year.

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

3542 U.S.C. S: 254l-1(f), (g). For the 2-year minimum service commitment,
NHSC will pay up to $50,000, based on the loan repayment recipient's
qualifying educational loans, with the potential to participate in the
program for additional years, one year at a time, with NHSC paying up to
$35,000 per year. See HRSA, Bureau of Health Professions, National Health
Service Corps, "Loan Repayment Program,"
http://nhsc.bhpr.hrsa.gov/join_us/lrp.asp (downloaded May 13, 2006).

3642 U.S.C. S: 254q-1. States must provide matching funds to be eligible
for a grant.

3769 Fed. Reg.70459 (Dec. 6, 2004). Applicants for the Ready Responders
must file a U.S. Public Health Service Commissioned Corps application and
meet the requirements for such commissioning. Initial assignments will
last up to 3 years, after which providers choosing to stay in the U.S.
Public Health Service move on to new assignments.

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

3942 U.S.C. S: 1395l(m).

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

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

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

43Foreign physicians may enter the United States for graduate medical
education as participants under an exchange visitor program administered
by the Department of State. These physicians enter the United States with
J-1 visas and are required to return to their home country or country of
last legal residence for at least 2 years when they complete their
graduate medical education. They may, however, obtain a waiver of this
requirement from the Department of Homeland Security's U.S. Citizenship
and Immigration Services (USCIS) at the request of a state or federal
agency, if the physician has agreed to practice in or work at a facility
that treats residents of a geographic area or areas designated by the
Secretary of Heath and Human Services as having a shortage of health care
professionals, such as a HPSA, for 3 years. 8 U.S.C. S: 1184(l)(1)(D). In
May 2006, we testified that, in fiscal year 2005, states and federal
agencies requested more than 1,000 waivers for physicians-including those
practicing primary care specialties and those practicing nonprimary care
specialties-to work in facilities that are located in, or treat residents
of, HPSAs or other underserved areas. More than 90 percent of these were
states' waiver requests; less than 10 percent were federal agencies'
requests. See GAO, Foreign Physicians: Preliminary Findings on the Use of
J-1 Visa Waivers to Practice in Underserved Areas, GAO-06-773T
(Washington, D.C.: May 18, 2006).

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

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

4642 U.S.C. S: 295p(6)(A), (B).

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

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

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

50See GAO/HEHS-95-200 .

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

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

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

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

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

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

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

5867 Fed. Reg. 7740-88 (Feb. 20, 2002).

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

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

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

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

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

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

bThe maximum HPSA score a health center can receive is 25.

In contrast, automatic facility HPSA designation made health centers
eligible, regardless of HPSA score, to apply in 2005 for a physician or
other health care provider through the NHSC Loan Repayment Program.62
According to an official with the National Association of Community Health
Centers, health center officials were pleased with this benefit but also
viewed it with caution because NHSC loan repayment awards are made first
to providers who agree to practice in higher-scoring HPSAs and then to
providers who agree to practice in lower-scoring HPSAs, in decreasing
order of HPSA score. Although NHSC had sufficient funding for all
qualifying loan repayment applicants from 2003 through 2005, health center
officials were concerned that in future years, NHSC funding may be
insufficient to sustain this benefit for health centers with relatively
low HPSA scores.

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

As of September 2005, 590 (16 percent) of the 3,637 rural health clinics
in the United States had received automatic designation as facility HPSAs.
To receive automatic designation, rural health clinics, unlike health
centers, must certify that they provide health care services regardless of
an individual's ability to pay. To qualify for automatic HPSA designation,
some rural health clinics-including those that are for-profit
entities-would have to restructure their billing practices, and according
to officials at the National Association of Rural Health Clinics and
HRSA's Office of Rural Health Policy, it may not be in their interest to
do so.

As with health centers, the main benefit cited by officials at the Office
of Rural Health Policy of automatic HPSA designation for rural health
clinics is to be eligible for NHSC physicians or other primary care
providers. Rural health clinics that were located in geographic or
population-group HPSAs would not benefit from automatic designation unless
the associated HPSA score was higher than the score for the geographic or
population-group HPSAs in which they were located. Data were not available
to determine how many of the 590 rural health clinics with automatic
facility HPSA designations were located in geographic or population-group
HPSAs before the 2002 provision was implemented. An official at the
National Association of Rural Health Clinics reported, however, that a
recent study estimated that over 70 percent of all rural health
clinics-including those that did not receive the automatic facility HPSA
designation-were located in geographic HPSAs before 2002 and were
therefore already eligible for federal programs requiring HPSA
designation.63

As of September 2005, less than 1 percent of the 590 rural health clinics
that had received automatic designation as facility HPSAs had associated
HPSA scores of 14 or higher needed to qualify for a physician through the
NHSC Scholarship Program or HHS's J-1 visa waiver program (see fig. 6).64
About 1 percent received a HPSA score of 13 or higher-the HPSA score
required by the NHSC Scholarship Program to qualify for a nurse
practitioner or physician assistant. Like health centers with lower HPSA
scores, rural health clinics automatically designated as facility HPSAs
but scoring lower than 14 could recruit a physician or other provider
through the NHSC Loan Repayment Program.65

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

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

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

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

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

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

bThe maximum HPSA score a rural health clinic can receive is 25.

                                  Conclusions

Many federal programs continue to rely on HPSA designations to allocate
federal resources or provide benefits, even though shortcomings we and
others have reported since 1995 have not been addressed. In particular,
the omission of important categories of primary care providers-such as
foreign physicians with J-1 visa waivers and nonphysician primary care
providers-from calculations for HPSA designation can overstate the need
for additional primary care providers. Although HHS has recognized the
need for improvements and has been working since 1998 on a proposal to
revise the HPSA designation system, it remains to be seen when HHS will
make such improvements and what changes will be made. In addition, HRSA
has not regularly removed the HPSA designation of those areas, population
groups, or facilities that no longer meet the designation criteria.

Available information suggests that the provision to automatically
designate health centers and certain rural health clinics as facility
HPSAs has benefited a relatively small number of these facilities. The
precise impact of the provision could not be measured, however, because of
limitations with available HHS data. For example, the available data did
not include sufficient geographic information to determine which of these
facilities were located in geographic or population-group HPSAs before
receiving automatic designation as facility HPSAs.

                      Recommendations for Executive Action

We recommend that the Secretary of Health and Human Services take the
following two actions: (1) publish a list of designated HPSAs in the
Federal Register or otherwise remove, through Federal Register
notification, the HPSA designations for those HPSAs that no longer meet
the criteria or have not provided updated data in support of their
designations and (2) complete and publish HHS's proposal to revise the
HPSA designation system and address the shortcomings that have been
identified in the current methodology for designating HPSAs.

                                Agency Comments

We received comments on a draft of this report from HHS (see app. V). The
department generally agreed with our findings and concurred with both
recommendations. Specifically, the department agreed that a more timely
publication of the Federal Register listing of designated HPSAs is
necessary to ensure that only those areas meeting the regulations remain
designated, and stated that HRSA should publish lists of HPSAs or HPSA
withdrawals to ensure that designations that have already been proposed
for withdrawal are actually withdrawn. The department also noted that it
is proposing a change in the process for withdrawing HPSA designations,
but it did not provide any details on this proposal. HHS also agreed with
our recommendation that the department complete and publish its proposal
to revise the HPSA designation system. HHS stated that this proposal would
address shortcomings that we identified in this and previous reports and
would also affect the regulations governing MUA and MUP designations.

HHS also commented on our finding that many health centers and rural
health clinics did not benefit from automatic designation as facility
HPSAs. Specifically, HHS stated that our draft report provided a somewhat
misleading assessment of the impact of the automatic designation process
and the department provided additional information on NHSC placements in
automatically designated HPSAs in 2005. Our draft report stated that few
health centers had HPSA scores associated with automatic designation that
were high enough to qualify for a physician through the NHSC Scholarship
Program, but that all health centers that received automatic designation
as HPSAs, even those with lower HPSA scores, could apply in 2005 for a
health care provider through the NHSC Loan Repayment Program. The data the
department provided on NHSC placements in automatically designated health
centers were actually consistent with the statement in our draft report.
HHS's data, which HHS officials said included both primary care and
nonprimary care providers, showed that of 216 NHSC providers placed in
health centers, relatively few (less than 5 percent) were placed through
the NHSC Scholarship Program and the NHSC Ready Responder Program (less
than 1 percent), whereas the vast majority (more than 95 percent) were
placed through the NHSC Loan Repayment Program. According to HRSA
officials, data for primary care provider placements (which were not
included in the department's comments), showed a similar distribution
between the three NHSC programs for 155 primary care NHSC placements in
health centers in 2005. In its comments, HHS also provided information on
the process for scoring automatically designated HPSAs and on NHSC and J-1
visa waiver programs. In response, we added information on J-1 visa waiver
programs administered by federal agencies other than HHS and by state
health departments.

Finally, HHS suggested that we clarify that our scope was limited to
primary care HPSAs. We made revisions to the report to highlight that our
review only examined primary care HPSA designations.

The department also provided technical comments, which we incorporated as
appropriate.

We are sending copies of this report to the Secretary of Health and Human
Services, the Administrator of HRSA, the Administrator of CMS, and to
appropriate congressional committees. We will also provide copies to
others upon request. In addition, the report will be available at no
charge on the GAO Web site at http://www.gao.gov .

If you or your staff members have any questions about this report, please
contact me at (312) 220-7600 or [email protected]. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on the
last page of this report. GAO staff members who made contributions to this
report are listed in appendix VI.

Leslie G. Aronovitz
Director, Health Care

Appendix I: Scoring of Health Professional Shortage Areas 

Each designated health professional shortage area (HPSA) receives a score
that the Department of Health and Human Services's (HHS) Health Resources
and Services Administration (HRSA) uses to rank its shortage of primary
care providers, or need, relative to other HPSAs. The HPSA score is used
by some federal programs, such as the National Health Service Corps (NHSC)
Scholarship Program, which requires participants to practice in locations
with higher HPSA scores. The scores, ranging from 0 to 25, are based on
four factors, for which each HPSA is given a certain number of points (see
fig. 7). To calculate a HPSA score, points for the population-to-primary
care physician ratio, ranging from 1 to 5 points, are doubled and then
summed with the points for each of the other three factors. For health
centers and rural health clinics receiving automatic designation as
facility HPSAs, if complete data are not available, or if HRSA cannot
match the facility to appropriate data to calculate a HPSA score, the HPSA
receives either a score of 0 or a partial score based on the sum of
factors for which data are obtainable.

Figure 7: Scoring of HPSAs, 2005

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

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

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

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

Medically underserved areas (MUA) and medically underserved populations
(MUP) generally are areas, or populations within areas, that are
designated by HHS's HRSA as having a shortage of health care services. The
MUA and MUP designations were developed about the same time as the HPSA
designation system but independently from it. Authorized by the Health
Maintenance Organization Act of 1973, MUA and MUP designations have been
used for identifying areas eligible to participate in the consolidated
health center program. That is, in order to receive health center grant
funding as a community health center, migrant health center, or a center
serving residents of public housing or the homeless, the health center
must be located in or serve the residents of an MUA or MUP.

MUAs are designated for the entire population of a particular geographic
area. MUP designations are limited to particular groups of underserved
people within an area. Individual facilities are not eligible for MUA or
MUP designations as they are under the HPSA designation system. As of
September 2005, HRSA had designated 3,443 geographic areas as MUAs and 488
population groups as MUPs.

HRSA designates MUAs and MUPs on the basis of four factors of health
service need, the first three of which are also used for HPSA designation
or scoring:

           o  ratio of population to number of primary care physicians,

           o  infant mortality rate,

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

           o  percentage of population aged 65 or over.

           To determine if an area meets the criteria to be designated as an
           MUA or if a population within an area meets the criteria to be
           designated as an MUP, each factor is assigned a weighted value,
           and these values are summed to obtain a combined score.1 This
           score is used to determine if an area or population can be
           designated as an MUA or MUP. Areas and populations in the country
           are ranked using this score to determine their order of need of
           health services. Areas and populations with scores at or below 62
           (the median score that was calculated for all U.S. counties in
           1975 for the four criteria) are designated MUAs or MUPs. Those
           populations within areas with scores above 62 may still be
           designated as MUPs if they demonstrate that unusual local
           conditions impede access to or the availability of personal health
           services. Such requests must be documented and recommended by the
           state chief executive officer and the responsible local officials.

           One of the ways in which MUAs and MUPs differ from HPSAs is that
           MUA and MUP designations are not required to be regularly updated.
           According to a HRSA official, some areas with MUA or MUP
           designations have not been reviewed since the 1980s. In 1998, HHS
           published a proposal in the Federal Register to revise the MUA and
           MUP designations and combine them with the HPSA designation
           system.2 The department received over 800 comments on the
           proposal; subsequently, HHS withdrew the proposal and began
           working on another one, which, as of September 2006, was in the
           department's clearance process.

           Another term-medically underserved community-is used to identify
           underserved areas for purposes of funding preferences for health
           professions education and training programs authorized under title
           VII of the Public Health Service Act.3 A medically underserved
           community is defined as an urban or rural area or population that

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

           o  has a shortage of personal health services, as determined under
           criteria issued by the Secretary of Health and Human Services
           under section 1861(aa)(2) of the Social Security Act (relating to
           rural health clinics); or

           o  is designated by a state governor (in consultation with the
           medical community) as a shortage area or medically underserved
           community.4

           In fiscal year 2005, 15 programs authorized under title VII, with
           funding of more than $160 million, provided funding preferences
           for any qualified applicant, such as a health professions school,
           that had a high rate for placing graduates in practice settings
           having the principal focus of serving residents of medically
           underserved communities or that achieved a significant increase in
           the rate of placing graduates in such settings during the previous
           2-year period.5

           In addition, two nursing traineeship programs authorized under
           title VIII of the Public Health Service Act used the medically
           underserved community definition in providing a funding preference
           to grant applicants. Title VIII provides a funding preference that
           includes nursing workforce grant applicants with projects that
           will substantially benefit rural or underserved populations.6 For
           purposes of this statutory funding preference for two title VIII
           programs-the Advanced Education Nursing Traineeship Program and
           Nurse Anesthetist Traineeship Program-HHS used established
           clinical sites identified under the definition of medically
           underserved community as proxies for rural and underserved
           populations. In fiscal year 2005, these two programs authorized
           under title VIII had about $17 million in funding.

           To conduct our work, we examined relevant laws, regulations, and
           HHS documents related to the HPSA criteria and designation
           methodology that were in effect in 2005 for primary care HPSAs,
           and reviewed our prior work on the HPSA designation system.

           To determine the number of HPSAs, we interviewed officials from
           HRSA, who reported that precise, accurate, historical data on the
           total number of HPSAs were not available. Therefore, we designed a
           methodology that HRSA officials confirmed was reasonable for
           estimating the number of HPSAs designated as of September 2005. We
           used the following HRSA data sources for our methodology:

           o  For geographic and population-group HPSAs, we obtained and
           analyzed summary statistics on HPSA designations as of September
           2005 from the Shortage Designation Branch within HRSA's Bureau of
           Health Professions.

           o  For facility HPSAs that were federal or state correctional
           institutions and public or nonprofit medical facilities, we
           reviewed a more detailed HRSA database of HPSAs designated as of
           September 2005, downloaded from HRSA's Geospatial Data Warehouse.1

           o  For facility HPSAs that were health centers and rural health
           clinics with automatic facility HPSA designations, we analyzed
           HRSA's data files of facilities with automatic HPSA designations
           as of September 2005.

           We also analyzed HRSA data on the HPSA scores of health centers
           and rural health clinics that received automatic HPSA designation
           to determine which of these facilities qualified for federal
           programs that required a minimum HPSA score as of September 2005.
           In addition, we reviewed data as of January 2006 downloaded from
           HRSA's Geospatial Data Warehouse to identify the locations of
           geographic and population-group HPSAs and the HPSAs that were
           proposed to have their HPSA designations withdrawn because they no
           longer met the criteria or did not provide updated data in support
           of their designations.2

           We performed reliability checks on the HRSA data to identify
           potential duplicate entries or inconsistencies in the data-for
           example, inconsistencies between HRSA's published summary
           statistics and our analysis summarizing the data from HRSA's
           Geospatial Data Warehouse-and interviewed HRSA officials, Indian
           Health Service (IHS) officials, and officials from associations
           representing health centers and rural health clinics about the
           data. We accounted for limitations in the data by excluding from
           our analysis the lists of two categories of facility HPSAs-public
           or nonprofit medical facilities and Alaska Native health
           centers-that HRSA officials stated could have been duplicates of
           facilities in HRSA's data of health centers that received
           automatic HPSA designation and that HRSA had not yet identified as
           duplicates and removed from its data.3 In total, we excluded 136
           public or nonprofit medical facilities and 21 Alaska Native health
           centers. After taking these steps, we determined that the data
           were sufficiently reliable for our purposes.

           To obtain information on HPSA designation and federal programs
           that use HPSA designations, we reviewed Federal Register notices,
           laws, regulations, and documents from HHS's Centers for Medicare &
           Medicaid Services (CMS), HRSA, and IHS, including HRSA's National
           Health Service Corps (NHSC) summaries of the NHSC programs' field
           strength at the end of fiscal year 2005, and we reviewed our prior
           work on these programs.4

           To identify available research on the criteria used to designate
           HPSAs since we last reported on the criteria in 1995, we conducted
           a literature search of articles, studies, and reports-which we
           call reports-issued from January 1, 1995, through November 1,
           2005. We focused our review on the HPSA criteria that were in
           effect both in 2002 when the Health Care Safety Net Amendments
           were enacted and at the time of our review. We performed the
           literature search of peer-reviewed reports using the ProQuest
           search engine and keywords that were related to the following key
           elements of the HPSA designation criteria, including factors for
           determining areas with unusually high needs for primary medical
           care services:5

           o  ratio of population to primary care physicians,

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

           o  infant mortality rate,

           o  distance to health care services, and

           o  birth rate.

           We also identified reports published during that time frame
           related to the HPSA criteria or methodology from the
           bibliographies of relevant reports, recommendations from experts
           we interviewed, and our prior work. We did not independently
           assess the methods used in the reports we located.

           Of the more than 340 reports located through the search, we
           identified 12 reports that we determined to be potentially
           relevant.6 After reviewing these 12 reports, we found 1 report in
           a peer-reviewed journal published from January 1, 1995, through
           November 1, 2005, that addressed the relationship between one of
           the key elements of the HPSA designation criteria (income) and
           primary care physician shortages or supply. We selected this
           report because it met the following criteria, in addition to the
           criteria outlined above:

           o  The report assessed the relationship between at least one key
           element of the HPSA designation criteria and primary care
           physician shortages or supply at the county, metropolitan
           statistical area, health service area, or other local level.7

           o  The report used a definition of primary care similar to the
           definition used for the HPSA designation (e.g., general or family
           practice, general internal medicine, pediatrics, and obstetrics
           and gynecology).

           Of the 12 reports reviewed, 6 reports discussed aspects of the
           methodology used to designate HPSAs: 1 issued by the Council on
           Graduate Medical Education (COGME), 1 issued by the Cecil G. Sheps
           Center for Health Services Research at the University of North
           Carolina at Chapel Hill, and 4 published in peer-reviewed
           journals.

           To review the impact of the automatic designation on health
           centers and rural health clinics as facility HPSAs, we analyzed
           HRSA's data on automatic HPSA designations and their associated
           scores. We also analyzed data on rural health clinics prepared by
           the Cecil G. Sheps Center for Health Services Research at the
           University of North Carolina at Chapel Hill for HRSA's Office of
           Rural Health Policy, which used 2003 and 2004 CMS data on rural
           health clinics and 2005 HRSA data on HPSAs. However, limitations
           in these data prevented us from determining exactly how many
           health centers and rural health clinics benefited when all health
           centers and certain rural health clinics received automatic
           designation as a result of the provision included in the Health
           Care Safety Net Amendments of 2002. For example, the available
           data did not include sufficient geographic information to
           determine which of these facilities were located in geographic or
           population-group HPSAs before receiving automatic designation as
           facility HPSAs. Because of the data limitations, we also
           interviewed HHS officials in HRSA's Office of Rural Health Policy
           and Bureau of Primary Health Care, as well as officials from the
           National Association of Community Health Centers and the National
           Association of Rural Health Clinics, to discuss the impact of the
           automatic designation.

           We performed our work from August 2005 through September 2006 in
           accordance with generally accepted government auditing standards.

1Criteria for designation of MUAs and MUPs are based on the index of
medical underservice, published in the Federal Register on October 15,
1976, and on the provisions of Pub. L. No. 99-280, enacted in 1986. Areas
or populations are scored on a scale of 0 to 100, where 0 represents
completely underserved and 100 represents best served or least
underserved. Each service area or population group within an area found to
have a score of 62 or less qualifies for designation as an MUA or MUP. See
HRSA, Bureau of Health Professions, "Guidelines for Medically Underserved
Area and Population Designation,"
http://bhpr.hrsa.gov/shortage/muaguide.htm (downloaded on June 23, 2006).

263 Fed. Reg. 46538-55 (Sept. 1, 1998).

3Funding preferences are factors that place a grant application ahead of
others without a preference on a list of applicants recommended for
funding by a review committee.

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

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

642 U.S.C. S: 296d. The preference also applies to applicants that will
help meet public health nursing needs in state or local health
departments.

Appendix III: Scope and Methodology

1The HRSA Geospatial Data Warehouse provides a single point of access to
HRSA programmatic information, related health resources, and demographic
data for reporting on HRSA activities. The data warehouse provides access
to information for reporting and mapping of HRSA data, including HPSAs.
For more information, see HRSA, "HRSA Geospatial Data Warehouse,"
http://datawarehouse.hrsa.gov (downloaded Mar. 12, 2006). We downloaded
data on HPSA designations as of September 2005 from the data warehouse on
October 27, 2005. We limited our analysis of the HPSA database downloaded
from the data warehouse to those data elements that we determined,
following discussion with HRSA officials, were reliable for our purposes.

2We downloaded data on HPSA designations as of January 2006 from HRSA's
Geospatial Data Warehouse on March 12, 2006.

3As of May 2006, the HRSA official responsible for designating HPSAs said
that the agency was in the process of removing the duplicate entries of
health centers for Alaska Natives so these facilities would be counted
only once as a facility HPSA in HRSA's databases. The HRSA official also
reported that HRSA would remove duplicate public or nonprofit medical
facilities when these HPSA designations were reviewed for continued
eligibility.

4We reviewed information from these same sources to obtain information on
federal programs that use other federal designations of medical
underservice.

5The factors used to calculate the HPSA score were also generally
represented in our keywords.

6We identified reports as potentially relevant if they addressed the
relationship between key elements of the HPSA designation criteria and
primary care physician shortages or supply, including primary care
disciplines, such as pediatrics. We determined the following types of
reports not to be potentially relevant: those specific to other
disciplines or professions, such as dental care, chiropractic care,
specialty care, or nursing care; those related to recruitment and
retention of physicians that focused on physician characteristics; those
related to workforce projections; those using data from countries other
than the United States or focusing on health care markets outside of the
United States; and those with a narrow focus, such as on vaccine
shortages.

7We excluded reports that used state-level data because these data are not
necessarily applicable to smaller geographic units such as counties, and
HPSAs are often based on county boundaries or parts of counties.

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

           Various federal programs have used the HPSA, MUA, MUP or other
           designations, such as medically underserved communities, to
           allocate resources, such as scholarships or grants, or to provide
           benefits, such as the waiver of requirements associated with a
           foreign physician's visa (see table 2).

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

                 Agency                                                          
                 administering Resource                                          
                 program or    allocated or     Federal funding Designation(s)
Program       benefit       benefit provided informationa    used by program
Consolidated  HRSA and CMS  Awards grants    $1,734 million  MUA              
health center               for operation of (funding from                    
program                     health centers   FY 2005         MUP              
                               and other        appropriations  
                               activities;      for HRSA)b      
                               provides                         
                               benefits                         
                               associated with                  
                               federally                        
                               qualified health                 
                               center status,                   
                               including                        
                               eligibility to                   
                               participate in a                 
                               drug discount                    
                               program and to                   
                               receive                          
                               reimbursement                    
                               from Medicare                    
                               and Medicaid                     
                               using special                    
                               payment                          
                               mechanisms,                      
                               which serve as                   
                               an incentive for                 
                               becoming a                       
                               health center.                   
Federally     HRSA and CMS  Provides         b               MUA              
qualified                   benefits                                          
health center               associated with                  MUP              
look-alike                  federally                        
program                     qualified health                 
                               center status,                   
                               including                        
                               eligibility to                   
                               participate in a                 
                               drug discount                    
                               program and to                   
                               receive                          
                               reimbursement                    
                               from Medicare                    
                               and Medicaid                     
                               using special                    
                               payment                          
                               mechanisms,                      
                               which serve as                   
                               an incentive for                 
                               becoming a                       
                               health center.                   
Indian Health IHS           Awards American  $9 million      HPSAc            
Scholarship                 Indian and       (funding from   
Program                     Alaska Native    FY 2005         
                               students with    appropriations  
                               scholarships for for IHS)        
                               service in                       
                               certain                          
                               practices in                     
                               HPSAs or other                   
                               practice                         
                               locations                        
                               authorized by                    
                               statute.c                        
J-1 visa      Department of Waives           Not applicable  HPSAe            
waivers for   Homeland      requirement for                                   
physicians at Security's    certain foreign                  MUA              
the request   U.S.          physicians to                                     
of federal    Citizenship   return to their                  MUP              
agencies (3   and           home country or                  
programs)     Immigration   country of last                  
                 Services      legal residence                  
                 (USCIS),      for 2 years                      
                 Department of after graduate                   
                 State,        medical                          
                 Appalachian   education at the                 
                 Regional      request of an                    
                 Commission,   interested                       
                 Delta         federal agency                   
                 Regional      in exchange for                  
                 Authority,    at least 3 years                 
                 HHS's Office  of service in an                 
                 of Global     area designated                  
                 Health        by the Secretary                 
                 Affairs, and  of Health and                    
                 HRSAd         Human Services                   
                               as having a                      
                               shortage of                      
                               health                           
                               professionals.                   
J-1 visa      USCIS,        Waives           Not applicable  HPSA:f Practice  
waivers for   Department of requirement for                  in a HPSA or     
physicians at State, state  certain foreign                  treating the     
the request   health        physicians to                    residents of     
of state      departmentsd  return to their                  HPSAs            
health                      home country or                                   
departments                 country of last                  MUA: Practice in 
(also known                 legal residence                  an MUA or        
as the Conrad               for 2 years                      treating the     
Program)                    after graduate                   residents of     
                               medical                          MUAs             
                               education in                                      
                               exchange for at                  MUP: Practice in 
                               least 3 years of                 an MUP or        
                               service in an                    treating the     
                               area designated                  residents of     
                               by the Secretary                 MUPs             
                               of Health and                    
                               Human Services                   
                               as having a                      
                               shortage of                      
                               health                           
                               professionals.                   
                               Limited to 30                    
                               waivers per                      
                               state per year.                  
                               Up to five                       
                               waivers may be                   
                               for physicians                   
                               to practice                      
                               outside of                       
                               shortage areas                   
                               as long as they                  
                               practice in a                    
                               facility that                    
                               serves patients                  
                               residing in such                 
                               areas.                           
Medicare      CMS           Provides 10      $148 million    HPSA: Geographic 
Incentive                   percent bonus    (FY 2005        HPSAs only       
Payment                     payment on       Medicare        
program                     Medicare         expenditures)   
                               payments for                     
                               physician                        
                               services in                      
                               geographic                       
                               HPSAs.                           
National      HRSA          Awards           $131 million    HPSA             
Health                      scholarships to  (funding from   
Service Corps               or provides      FY 2005         
(4 programs)g               money to repay   appropriations  
                               educational      for HRSA)       
                               loans of                         
                               students and                     
                               health                           
                               professionals in                 
                               exchange for at                  
                               least 2 years of                 
                               service in a                     
                               HPSA; supports                   
                               commissioned                     
                               officers of the                  
                               U.S. Public                      
                               Health Service                   
                               to serve for 3                   
                               years in the                     
                               neediest HPSAs.                  
National      USCIS         Waives the job   Not applicable  HPSA: Geographic 
Interest                    offer                            HPSAs only       
Waivers for                 requirement                                       
Immigrant                   placed on                        MUA              
Physicians                  certain                          
                               immigrants,                      
                               including                        
                               physicians who                   
                               agree to                         
                               practice in a                    
                               HPSA, an MUA, an                 
                               MUP, or at                       
                               Department of                    
                               Veterans Affairs                 
                               facilities.h                     
Rural Health  CMS           Provides special $413 million    HPSA: Rural      
Clinic                      Medicare and     (2004 Medicare  geographic and   
program                     Medicaid payment expenditures);i population-group 
                               mechanisms for   $333 million    HPSAs only       
                               rural health     (FY 2004                         
                               clinics, which   Medicaid        MUA: Rural MUAs  
                               serve as an      expenditures)i  only             
                               incentive for                                     
                               becoming a rural                 Other: Rural     
                               health clinic.                   areas designated 
                                                                by a state's     
                                                                governor as      
                                                                shortage areas   
Scholarships  HRSA          Awards grants to $47 million     HPSA             
for                         health           (funding from                    
Disadvantaged               professions      FY 2005         MUA              
Students                    schools to       appropriations                   
Program                     provide          for HRSA)       MUP              
                               scholarships to                                   
                               full-time,                       Other: Other     
                               financially                      medically        
                               needy students                   underserved      
                               from                             communitiesk     
                               disadvantaged                    
                               backgrounds                      
                               enrolled in                      
                               eligible health                  
                               professions or                   
                               nursing                          
                               programs.                        
                               Funding priority                 
                               is given to                      
                               schools applying                 
                               for the funding                  
                               based on the                     
                               proportion of                    
                               graduating                       
                               students going                   
                               into primary                     
                               care, the                        
                               proportion of                    
                               underrepresented                 
                               minority                         
                               students, and                    
                               the proportion                   
                               of graduates                     
                               working in                       
                               medically                        
                               underserved                      
                               communities.j, k                 
Title VII     HRSA          Provides grants  $165 million    HPSA             
health                      for health       (funding from                    
professions                 professions      FY 2005         MUA              
education and               education and    appropriations                   
training                    training         for HRSA)       MUP              
grant                       programs.                                         
programsl (16               Funding                          Other: Other     
programs)                   preference is                    medically        
                               given to                         underserved      
                               applicants that                  communitiesk     
                               (1) place a high                 
                               or increasing                    
                               number of                        
                               graduates or                     
                               program                          
                               completers in                    
                               settings having                  
                               the principal                    
                               focus of serving                 
                               medically                        
                               underserved                      
                               communities or                   
                               (2) have 25                      
                               percent or more                  
                               of their                         
                               graduates in                     
                               full-time                        
                               practice                         
                               settings in                      
                               medically                        
                               underserved                      
                               communities and                  
                               meet other                       
                               statutory                        
                               requirements.k,                  
                               m                                
Title VIII    HRSA          Provides grants  $17 million     HPSA             
nursing                     to institutions  (funding from                    
education                   to provide       FY 2005         MUA              
programsn (2                financial        appropriations                   
programs)                   support through  for HRSA)       MUP              
                               traineeships for                                  
                               registered                       Other: Other     
                               nurses enrolled                  medically        
                               in advanced                      underserved      
                               education                        communitiesk     
                               nursing programs                 
                               or in a master's                 
                               degree nurse                     
                               anesthesia                       
                               program. In                      
                               awarding grants,                 
                               a funding                        
                               preference is                    
                               given to                         
                               applicants whose                 
                               projects will                    
                               substantially                    
                               benefit rural or                 
                               underserved                      
                               populations,                     
                               using sites                      
                               identified under                 
                               the definition                   
                               of medically                     
                               underserved                      
                               community as                     
                               proxies, and                     
                               gives special                    
                               consideration                    
                               for applicants                   
                               with students                    
                               who have                         
                               committed to                     
                               practicing in                    
                               HPSAs after                      
                               graduation.k, o                  

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

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

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

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

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

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

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

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

gNational Health Service Corps programs include the Scholarship Program,
federal Loan Repayment Program, State Loan Repayment Program, and Ready
Responders.

h8 U.S.C. S: 1153(b)(2)(B)(ii), 8 C.F.R. S: 204.12 (2006).

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

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

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

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

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

nIncludes the Advanced Education Nursing Traineeship Program and Nurse
Anesthetist Traineeship Program.

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

Appendix VI: GAO Contact and Staff Acknowledgments

                                  GAO Contact

Leslie G. Aronovitz, (312) 220-7600 or [email protected]

                                Acknowledgments

In addition to the person named above, Kim Yamane, Assistant Director;
Ellen W. Chu; Jennifer DeYoung; and Julian Klazkin made key contributions
to this report.

Related GAO Products

Foreign Physicians: Preliminary Findings on the Use of J-1 Visa Waivers to
Practice in Underserved Areas. GAO-06-773T . Washington, D.C.: May 18,
2006.

Health Professions Education Programs: Action Still Needed to Measure
Impact. GAO-06-55 . Washington, D.C.: February 28, 2006.

Health Centers: Competition for Grants and Efforts to Measure Performance
Have Increased. GAO-05-645 . Washington, D.C.: July 13, 2005.

Health Centers and Rural Clinics: State and Federal Implementation Issues
for Medicaid's New Payment System. GAO-05-452 . Washington, D.C.: June 17,
2005.

Health Workforce: Ensuring Adequate Supply and Distribution Remains
Challenging. GAO-01-1042T . Washington, D.C.: August 1, 2001.

Health Care Access: Programs for Underserved Populations Could Be
Improved. GAO/T-HEHS-00-81 . Washington, D.C.: March 23, 2000.

Physician Shortage Areas: Medicare Incentive Payments Not an Effective
Approach to Improve Access. GAO/HEHS-99-36 . Washington, D.C.: February
26, 1999.

Health Care Access: Opportunities to Target Programs and Improve
Accountability. GAO/T-HEHS-97-204 . Washington, D.C.: September 11, 1997.

Rural Health Clinics: Rising Program Expenditures Not Focused on Improving
Care in Isolated Areas. GAO/T-HEHS-97-65 . Washington, D.C.: February 13,
1997.

National Health Service Corps: Opportunities to Stretch Scarce Dollars and
Improve Provider Placement. GAO/HEHS-96-28 . Washington, D.C.: November
24, 1995.

Health Care Shortage Areas: Designations Not a Useful Tool for Directing
Resources to the Underserved. GAO/HEHS-95-200 .Washington, D.C.: September
8, 1995.

(290486)

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www.gao.gov/cgi-bin/getrpt? GAO-07-84 .

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and methodology, click on the link above.

For more information, contact Leslie G. Aronovitz at (312) 220-7600 or
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Highlights of GAO-07-84 , a report to congressional committees

October 2006

HEALTH PROFESSIONAL SHORTAGE AREAS

Problems Remain with Primary Care Shortage Area Designation System

To identify areas facing shortages of health care providers, HHS relies on
its health professional shortage area (HPSA) designation system. HHS
designates geographic, population-group, and facility HPSAs. HHS also
gives each HPSA a score to rank its need for providers relative to other
HPSAs.

The Health Care Safety Net Amendments of 2002 required GAO to report on
the HPSA designation system. GAO reviewed (1) the number and location of
HPSAs and federal programs that use HPSA designations to allocate
resources or provide benefits, (2) available research on HPSA designation
criteria and methodology, and (3) the impact of a 2002 provision that
automatically designates federally qualified health centers and certain
rural health clinics as facility HPSAs. GAO obtained and analyzed HHS's
data on primary care HPSA designations as of September 2005 and January
2006 and identified reports on HPSA criteria and methodology through a
literature search of peer-reviewed journals and other reports published
since 1995.

What GAO Recommends

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

GAO identified more than 5,500 HPSAs designated throughout the United
States as of September 2005; multiple federal programs relied on these
designations to allocate resources or provide benefits. GAO estimated that
slightly more than half of the HPSAs were designated for geographic areas,
such as counties or portions of counties, or population groups, such as
migrant farmworkers. The remaining HPSAs were designated for facilities,
such as rural health clinics. In fiscal year 2005, more than 30 federal
programs relied on HPSA designations, and in some cases HPSA scores, to
allocate resources or provide benefits. The use of the HPSA designation by
numerous federal programs to allocate resources or provide benefits is an
incentive for obtaining and retaining a HPSA designation.

Published reports have pointed to shortcomings in the methodology used for
designating HPSAs. These reports' observations were consistent with
findings in GAO's 1995 report, Health Care Shortage Areas: Designations
Not a Useful Tool for Directing Resources to the Underserved,
(GAO/HEHS-95-200, Sept. 8, 1995), including that HHS's methodology did not
account for certain types of primary care providers already serving in a
HPSA, which can result in an overstatement of the provider shortage.
Recognizing the shortcomings of the current methodology, HHS has been
working since 1998 on a proposal to revise the designation system. In
addition, some HPSAs that no longer meet the criteria have retained their
HPSA designation and possibly received benefits from federal programs that
rely on that designation. HHS has not complied since 2002 with the
statutory requirement to annually publish a list of designated HPSAs in
the Federal Register-which would remove the designations of those HPSAs
that are no longer listed.

Many federally qualified health centers and rural health clinics did not
benefit from automatic designation as facility HPSAs because they were
located in geographic or population-group HPSAs. In addition, most of the
more than 1,600 federally qualified health centers received HPSA scores
associated with the automatic designation that were too low to qualify
them for certain federal programs that required a minimum HPSA score in
2005, although they qualified for other programs that did not have such a
requirement. Of the 590 rural health clinics that chose to certify that
they would treat anyone regardless of ability to pay and, as a result,
received automatic designation as facility HPSAs, most also received
associated HPSA scores too low to qualify for benefits from certain
federal programs that required a higher HPSA score.
*** End of document. ***