Guidelines for
Primary Medical Care/Dental HPSA Designation
Also see:
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.
Primary
Care Specialty |
Average
Office Hours per Week 1/ |
Average
Hours All Direct Patient Care per Week 2/ |
Ratio
of Office Hours to All Direct Patient Care
Hours |
Office
Hours
to All Direct Patient Care Hours Adjustment
Factor |
General/Family |
35.1 |
49.9 |
.703 |
1.4 |
Practice
Pediatrics |
31.9 |
46.0 |
.693 |
1.4 |
Internal |
27.1 |
49.5 |
.547 |
1.8 |
Medicine
Obstetrics / Gynecology |
29.2 |
55.5 |
.526 |
1.9 |
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All
Primary Care 3/ |
30.8 |
50.1 |
.618 |
1.6 |
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. 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.
- 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.
- 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:
Sub-specialty:
Location of Practice:
Additional Office 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
Does the physician offer a sliding fee scale based
on income or ability to pay? Yes/No
Does the physician or others on staff offer language
interpretation for patients? Yes/No
Does the physician see migrant farmworkers as patients?
Yes/No
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:
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:
Sub-specialty:
Location of Practice:
Additional Office Location:
Does the dentist serve Medicaid patients? Yes/No
Does the dentist offer a sliding fee scale based
on income or ability to pay? Yes/No
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
Does the dentist see migrant farmworkers as patients?
Yes/No
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:
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