Shortage Designation: HPSAs, MUAs & MUPs

Also see:

• HPSA Designation Criteria
• Primary Medical HPSA Designation Overview
• HPSA Designation Criteria for Primary Medical Care
• Dental HPSA Designation Overview
• HPSA Designation Criteria for Dental

BACKGROUND/SUMMARY

Section 332 of the Public Health Service Act provides that the Secretary of Health and Human Services shall designate health professional shortage areas, or HPSAs, based on criteria established by regulation. The authority for designation of HPSAs is delegated to the Bureau of Primary Health Care's Division of Shortage Designation (DSD). Criteria and the process used for designation of HPSAs were developed in accordance with the requirements of Section 332. Designation as a HPSA is a prerequisite to application for National Health Service Corps (NHSC) Recruitment assistance.

The HPSA criteria require three basic determinations for a geographic area request: (1) the geographic area involved must be rational for the delivery of health services, (2) a specified population-to- practitioner ratio representing shortage must be exceeded within the area, and (3) resources in contiguous areas must be shown to be overutilized, excessively distant, or otherwise inaccessible. These criteria have been defined for shortage of primary medical care physicians, dentists, and mental health professionals. The particular level used to indicate primary medical care, dental, and mental health shortage is referenced in the Criteria for Designation of HPSAs, codified at 42 CFR Chapter 1, PART 5 - DESIGNATION OF HEALTH PROFESSIONAL(S) SHORTAGE AREAS, 10-1-93 edition.

Where a geographic area does not meet the shortage criteria, but a population group within the area has access barriers, a population group designation may be possible. In such cases the population group and the access barriers must be defined/described, and the ratio of the number of persons in the population group to the number of practitioners serving it must be determined. These ratios are also referenced in the Criteria for Designation of HPSAs.

In some cases, facilities may be designated as HPSAs. This applies to correctional facilities and to State mental hospitals. In addition, public and non-profit private facilities located outside designated HPSAs may receive facility HPSA designation if they are shown to be accessible to and serving a designated geographic area or population group HPSA.

A current list of designated HPSAs is published periodically; the most recent was published in the Federal Register on MAy 30, 1997. Designations more than 3 years old are subject to updating as part of the DSD's annual review of HPSAs. At that time, new data relevant to the designation should be sumbitted to the DSD in support of its continued status as a HPSA.

REQUIRED INFORMATION FOR HPSA REQUESTS

1. Rational Service Area - A map showing the boundaries of the area for which designation is being requested should be provided. The rationale for the selection of a particular service area definition (in terms of travel times, composition of the population, etc.) should be described, particularly for non-whole- county service areas and population groups. The area should be defined in in terms of counties or whole census tracts (CTs), census county divisions (CCDs), block numbering areas (BNAs), or minor civil divisions (MCDs).

2. Population Count - the number of persons in the requested area (or population group), based on the latest available Census Bureau or State population estimates (population projections will not be accepted). Any adjustments to the population count for the service area and contiguous areas should be explained.

3. Practitioner Count - the number of full-time- equivalent (FTE) non-Federal practitioners available to provide patient care to the area or population group. "Non-Federal" means practitioners who are not Federal employees and are not obligated-service members of the National Health Service Corps. It would include non-obligated-service hires of Federal grantees.

"Practitioner" means allopathic (M.D.) or osteopathic (D.O.) primary medical care physicians for primary medical care HPSA requests; dentists, for dental HPSA requests; and psychiatrists or core mental health providers for psychiatric/mental health HPSA requests. Core mental health providers include psychiatrists, clinical psychologists, clinical social workers, psychiatric nurse specialists, and marriage and family specialists.

"Patient care" for primary care physicians includes seeing patients in the office, on hospital rounds and in other settings, and activities such as interpreting laboratory tests and X-rays and consulting with other physicians.

To develop a comprehensive list of practitioners in an area, the applicant should check State licensure lists, State and local medical or dental society directories, local hospital admitting physician listings, Medicaid and Medicare practitioner lists, and the local yellow pages listings. For practitioners who serve in the requested area less than full-time (40 hours a week in patient care activities), an explanation is needed concerning a practitioner's part-time status (i.e. semi-retired, other practice location outside service area, teaching, etc.).

Calculating Primary Care FTE When Only Office Hours are Known

To determine primary medical care FTE in cases where only a physician's office hours are known, and information is not available on a physician's hours spent in other patient care activities, an upward adjustment must normally be made from the number of office hours per week to obtain the total estimated number of hours spent in direct patient care per week. The adjustment factors provided in the table below are designed to take into consideration the hours of direct patient care provided in both office and inpatient settings.

The first column of the table below lists the average number of hours per week that each type of primary care physician spends providing patient care in the office setting. The second column lists the average number of hours each spends in all direct patient care. The ratio of office hours to total direct patient care hours is shown in the third column. The last column presents the reciprocal of that ratio - the factor by which each type of physician's office hours should be multiplied to obtain his/her total hours in direct patient care.

To obtain a full-time-equivalency for a given physician, his/her total office hours per week should be multiplied by the appropriate factor for his/her specialty. In the event that the primary care specialty is unspecified, the factor shown for "all primary care" should be used. If this calculation yields a number greater than 40, the physician should be considered as 1.0 FTE; otherwise, this number of hours should be divided by 40 to obtain the physician's FTE.

^1/ American Medical Association, Socioeconomic Characteristics of Medical Practice, 1990-1991, Table 14, p. 58.^2/ Ibid, Table 11, p. 52.
^3/ This is a weighted average, weighted by the percentage that each specialty represents of all primary care physicians, using data from American Medical Association, Physician Characteristics and Distribution in the U.S., 1993 Edition, Table B-11a, p.59.

The criteria provides for counting primary medical care interns and residents as 0.1 FTE. This FTE should be counted at the location the intern or resident provides primary care, such as a hospital outpatient clinic or local health department clinic. If the clinic or other service site has "slots" which interns or residents rotate through during the year, then that slot will be counted at 0.1 FTE.

There is no provision in the HPSA criteria for counting dental interns or residents.

Psychiatric residents are counted at 0.5 FTE at their service site; the slot approach outlined above for primary care may be used in determining FTE.

4. Contiguous Resources - the availability and accessibility of health providers in contiguous areas. When showing that contiguous resources are excessively distant (greater than 30 minutes travel time for primary medical care, greater than 40 minutes for dental and mental health), the driving distance and travel time between the population center of the requested area and the population centers of the contiguous areas should be provided.

In inner portions of metropolitan areas travel time by public transportation will be used. By this is meant those inner city neighborhoods with significant poverty levels (20 percent or higher) indicative of a dependence on public transportation. In those city neighborhoods with relatively low poverty levels (where residents may elect to use public transportation), driving times will be used.

5. High Needs/Insufficient Capacity - the presence of indicators of unusually high needs of the population or insufficient capacity of health care resources in the area. The high needs factors for primary care, dental and mental health, and the insufficient capacity factors for existing primary care and dental providers, are detailed in the criteria.

Population Group HPSA Requests

The following is an update and clarification to the "Guidelines on Designation of Population Groups with Health Manpower Shortages" published in the Federal Register on November 5, 1982.

The geographic area within which the population group resides should be defined in terms of counties, civil divisions or census tracts, in accordance with the same rational service area criteria for designation of geographic areas.

The request should contain a description of the barriers to access, in the area of residence and contiguous areas, experienced by the population group. This description should contain appropriate supporting data and should address the following points:

1. 1. Whether the barriers to access for the population group are primarily economic in nature, or primarily due to non-economic factors such as minority status, language differences, or cultural differences. If significant numbers of practitioners (public and/or private) refuse to accept patients on the basis of non-economic factors, this problem and its extent should be discussed. If an access barrier appears to exist because of demographic or other differences between the population group and available practitioner(s) (public and/or private), this should also be discussed and evidence of it should be presented.
2. With respect to economic barriers, whether the major difficulty is lack of access for the low-income population or lack of access for the Medicaid-eligible population, the applicant should provide information on the number of persons in the category for which designation is requested. A minimum of 30 percent of the service area's population must be at or below 200 percent of poverty for consideration as a low- income or Medicaid-eligible population group HPSA.
3. Whether practitioners, health centers, or hospital outpatient clinics (public and/or private) in the area accept Medicaid reimbursement and/or provide patient care on an ability-to-pay or sliding-fee-scale basis. The applicant should list the practitioners, their practice locations and the approximate percentage of the practice devoted to the Medicaid-eligible population and the percentage of the practice devoted to other low-income persons in each such setting. FTE practitioners (D) is the number of practitioners involved, adjusted by the percentage of their time in patient care in the area, further adjusted by the estimated percentage of the time devoted to serving the population group in question.

In order to calculate the appropriate population-to-practitioner ratio (R) for consideration as a primary medical care, dental or mental health HPSA, the request should include the total number of persons in the population group for which designation is requested and the total number of FTE practitioners (D) in the defined area that are serving that population. The appropriate ratio (R) will then be computed as follows for these specific population groups:

Low-income populations

Low-income population, defined as those persons with incomes at or below 200 percent of the poverty level. A minimum of 30 percent of the requested area of residence's population must be at or below 200 percent of poverty for consideration under this population group category. This is also the population eligible to receive services on a sliding-fee scale at Federally-funded projects. This includes and replaces the previously separate category of medically indigent population.

N = Population with incomes at or below 200 percent of the poverty level D = FTE non-Federal practitioners serving the Medicaid population
+ FTE non-Federal practitioners offering care on a sliding-fee- scale, ability-to-pay basis, or free-of-charge basis R = N/D

Medicaid-eligible populations

A minimum of 30 percent of the requested area of residence's population must have incomes at or below 200 percent of the poverty level for consideration under this population group category.

N = population eligible for Medicaid under applicable State's medical assistance program
D = FTE non-Federal practitioners accepting Medicaid
R = N/D

Migrant (or Migrant and Seasonal) Farmworkers and their families (Revised to explicitly include Seasonals where appropriate)

N = (average daily number of migrant workers, or migrant and seasonal workers, and dependents present in the area during portion of year that migrants, or migrant and seasonal workers, are present) X (fraction of year migrants, or migrant and seasonal workers, are present)
D = FTE non-Federal practitioners serving migrants, or migrants and seasonal workers
R = N/D

American Indians or Alaskan Natives

N = number of American Indians or Alaskan Natives
D = FTE non-Federal practitioners serving Indians or Alaskan natives
R = N/D

Other populations isolated by linguistic or cultural barriers or by handicaps

N = number of people in language or cultural or handicapped group involved
D = FTE non-Federal practitioners speaking language involved (or using interpreter), or familiar with culture involved, or serving handicapped group
R = N/D

Homeless Populations

Public Law 100-77 included a provision amending Section 332 of the PHS Act to specifically state that the homeless are one of the population groups eligible for health professional shortage area (HPSA) designation. In fact, designation of homeless populations as HPSAs was already possible under existing legislation, regulations and criteria, and such designations already exist. The area where the homeless congregate should be defined in terms of census tracts, and information on the location of any homeless shelters, clinics, or other facilities serving the homeless should be provided.

N = The estimated number of homeless persons in the area, as recognized by local officials for planning of shelters/services to the homeless. Please include a brief description (or enclose an existing report) on how the count was obtained.
D = The number of full-time-equivalent (FTE) non-Federal practitioners, if any, currently serving the population. This would include time devoted to the homeless by practitioners at any local health care facilities which provide some ambulatory care services to the homeless, or by private practitioners who volunteer some of their time to serve the homeless at shelters or other locations accessible to homeless persons.
R = N/D

FEDERAL PROGRAMS USING HPSA DESIGNATIONS INCLUDE:

National Health Service Corps (Section 333 of the Public Health Service Act) - provides for assignment of federally-employed and/or service- obligated physicians, dentists, and other health professionals to designated HPSAs

National Health Service Corps Scholarship Programs (Section 338A) - provides scholarships for training of health professionals who agree to serve in designated HPSAs through the NHSC or the private practice option

National Health Service Corps Loan Repayment Program (Section 338B) - provides loan repayment to health professionals who agree to serve in the NHSC in HPSAs selected by the Secretary

Rural Health Clinics Act (Public Law 95-210) - provides Medicare and Medicaid reimbursement for services provided by physician assistants and nurse-practitioners in clinics in rural HPSAs

Medicare Incentive Payments for Physician's Services Furnished in HPSAs (Public Law 100-203, Section 4043, as amended) - CMS (formerly HCFA) gives 10 percent bonus payment for Medicare-reimbursable physician services provided within geographic HPSAs. This payment does not apply to population group HPSAs.

Higher "Customary Charges" for New Physicians in HPSAs (Public Law 100-203, Section 4047) - CMS (formerly HCFA) exempts new physicians opening practices in non-metropolitan geographic HPSAs from new Medicare limitations on "customary charges"

Area Health Education Center Program (Section 781(a)(1)) - gives special consideration to centers that would serve HPSAs with higher percentages of underserved minorities; gives funding priority to centers providing substantial training experience in HPSAs

Federal Employees Health Benefits Programs - provides reimbursement for non-physician services in States with high percentages of their population residing in HPSAs

(Revised October, 1995 - BPHC/Division of Shortage Designation)

Sample Survey for Determining Primary Care Physician FTE

The following may be used as a guide for both geographic and population group primary medical care HPSA requests. This information should be collected for each primary care physician at a practice location. All questions may not apply to a specific HPSA designation request.

Physician's name:

Specialty:

• Percent of Practice:

Sub-specialty:

• Percent of Practice:

Location of Practice:

• City:

• Zip:

• How many hours a week is the physician engaged in patient care activities at this location?

Additional Office Location:

• City:

• Zip:

• How many hours a week is the physician engaged in patient care activities at this location?

Does the physician have hospital admitting privileges, and if so, does the physician follow up with patients at the hospital? Yes/No

If a physician works less than 40 hours a week in patient care, a brief explanation should be provided (i.e. semi-retired, teaching, etc.):

Does the physician serve Medicaid patients? Yes/No

• If yes, what percent of his/her practice?

Does the physician offer a sliding fee scale based on income or ability to pay? Yes/No

• If yes, what percent of his/her practice?

Does the physician or others on staff offer language interpretation for patients? Yes/No

• If yes, what languages?

Does the physician see migrant farmworkers as patients? Yes/No

• If yes, what percent of your practice?

Is the physician currently accepting new patients? Yes/No

When a patient calls the physician's office to request an appointment, what is the usual elapsed time between the request and the appointment for:

• a new patient? Days/Weeks

• an established patient? Days/Weeks

Sample Survey for Determining Dental FTE

The following may be used as a guide for both geographic and population group dental HPSA requests. This information should be collected for all dentists at a practice location. All questions may not apply to a specific HPSA designation request.

Dentist's name:

Specialty:

• Percent of Practice:

Sub-specialty:

• Percent of Practice:

Location of Practice:

• City:

• Zip:

• How many hours a week does the dentist spend in his/her dental practice at this location?

Additional Office Location:

• City:

• Zip:

• How many hours a week does the dentist spend in his/her dental practice at this location?

Does the dentist serve Medicaid patients? Yes/No

• If yes, what percent of his/her practice?

Does the dentist offer a sliding fee scale based on income or ability to pay? Yes/No

• If yes, what percent of his/her practice?

If a dentist works less than a total of 40 hours a week in patientcare, a brief explanation (i.e. semi-retired, teaching, etc.) should be provided:

How many dental auxiliaries (e.g. dental hygenists or dental assistants) assist the dentist in providing dental care?

The dentist's age is:

• 54 years old or younger

• between 55-59 years old

• between 60-64 years old

• 65 years or older

Does the dentist or others on your staff offer language interpretation? Yes/No

• If yes, what languages?

Does the dentist see migrant farmworkers as patients? Yes/No

• If yes, what percent of his/her practice?

Is the dentist currently accepting new patients? Yes/No

When a patient calls the dentist's office to request an appointment, what is the usual elapsed time between the request and the appointment for:

• a new patient? Days/Weeks

• an established patient? Days/Weeks