Automatic
Facility HPSA Scoring
The Health Care Safety Net Amendments
of 2002 provided for automatic facility
Health Professional Shortage Area (HPSA)
status for all Federally Qualified Health
Centers (FQHCs) and those Rural Health
Clinics (RHCs) that meet the requirement
of providing access to care regardless
of ability to pay.
Note that FQHCs as used herein includes
several types of FQHCs:
(a) Health Centers (HCs) funded under
Section 330 of the PHS Act;
(b) FQHC “Look-Alikes” (or
FQHCLAs) that have been identified by
HRSA and certified by CMS as meeting
the definition of a Health Center in
Section 330, although they do not receive
grant funding; and
(c) outpatient health programs/facilities
operated by tribal organizations (under
the Indian Self-Determination Act) or
urban Indian organizations (under the
Indian Health Care Improvement Act).
All then-currently-qualified FQHCs were
given HPSA status as of the date of the
legislation; new FQHCs receive HPSA status
on the date on which they become FQHCs,
based either on Section 330 funding or
on certification as an FQHC Look-Alike.
Each FQHC is HPSA-designated as an entity,
encompassing all service locations included
in the approved scope of work.
To be considered automatically designated,
current RHCs were required to submit a
form confirming compliance with the ability-to-pay
requirement, and are considered as a HPSA
as of the date the form certifying compliance
is received. Each RHC is considered a
separate entity, even if part of a larger
organization.
Need for HPSA
Scoring
The automatic facility HPSA provisions
did not include any mechanism for prioritizing
automatic HPSAs relative to each other
or to other HPSAs, as required to implement
the National Health Service Corps (NHSC)
authorizing legislation.
The “HPSA score,” computed
from data submitted with a designation
request, is used to rank non-automatic
HPSAs according to need for NHSC purposes.
In the absence of the area- or facility-specific
data submitted with designation requests,
a scoring process for the automatic FQHC
and RHC HPSAs had to be developed using
nationally available data sources. At
the same time, it was recognized that
Federally Recognized Native American Tribes
and Alaskan Natives have been automatically
designated as population group HPSAs for
over 20 years, and no scoring methodology
was in place for these HPSAs either. To
remedy this, nationally available data
have now been used to calculate HPSA scores
not only for FQHCs and RHCs but also for
Native American tribal and Alaska Native
sites, using the HPSA scoring methodology
currently in use for geographic areas
and non-automatic population groups.
Scoring Process;
Data used to Compute Automatic HPSA Scores
The current scoring methodology
for primary care includes four factors:
Population-to-Primary Care Physician Ratio,
Percent of the Population with Incomes
below 100% of the Poverty level, Infant
Mortality Rate or Low Birth Weight Rate
(whichever scores more highly), and Travel
Time or Distance to nearest available
source of care (whichever scores more
highly). There is a transformation scale
that allows computation of partial scores
for each of these factors (see Criteria
for Determining Primary Care HPSAs of
Greatest Shortage), and the sum of
these partial scores form the total HPSA
score, except that the partial score for
Population-to-Primary Care Physician Ratio
is double-weighted, since HPSA designation
is primarily intended to measure the shortage
of primary care providers in the HPSA.
The data used to calculate the scores
for the automatic HPSAs were:
Population-to-Primary Care
Physician Ratio
For the FQHC grantees, FQHCLAs
and RHCs, these ratios were calculated
for the defined Primary Care Service
Area (PCSA) which included the location
of the facility, as an approximation
to the service area of the facility.
Resident civilian population data from
the census were used, and primary care
physician data were taken from the combined
AMA/AOA files used by the Shortage Designation
Branch.
For the IHS Service Units and the Alaska
Native facilities, Native American or
Alaska Native population figures from
the IHS or the Alaska Native Health
System were used, and physician data
represent the non-federal providers
in the area as reported by the IHS or
the Alaska Native Health System.
Infant Mortality Rates/Low
Birth Weight Rates: For FQHC
grantees, FQHCLAs and RHCs, IMR/LBW
rates for the PCSAs including the FQHC
or RHC were used.
For IHS and Alaska Native scoring, service
unit data for the appropriate populations
were used.
Poverty Rates
For FQHC grantees, 2002 UDS-reported
data on percent of users with incomes
below 100% of poverty were used. For
FQHCLAs and RHCs, the 2000 census poverty
data for the county of location were
used.
For the IHS and Alaska Native areas,
the census poverty data for Native American
populations within those areas were
used.
Travel Time/Distance to Nearest
Available Source of Care
For FQHC grantees, FQHCLAs, and RHCs,
travel time and distance were calculated
from the population-weighted center
of the PCSA in which the entity was
located to the population-weighted center
of the nearest PCSA with a population-to-primary
care physician ratio of at least 2000:1,
using average road speeds and travel
time for each road segment involved.
For IHS and Alaska Natives, data reported
by the IHS or the Alaska Native Health
System were used.
Multi-Site Entities
FQHCs with multiple sites received a
score for the entire entity. This entity
score was calculated by averaging the
individual site scores computed for
each component site.
Please note that inability to geocode
some locations, particularly in Alaska,
Hawaii, Puerto Rico, and the Pacific Basin,
results in the inability to collect appropriate
data for the scoring process. As a result,
there are some entities that still have
no score, or have a very low score due
to lack of data on some components.
The process outlined above has been completed
only for primary care HPSA scores. There
are incomplete data sources for some components
of the dental and mental health HPSA scoring
processes; partial scores are currently
being calculated for these disciplines.
Applicability
of Automatic HPSA Scores
These scores have been developed
for use in the 2005 recruitment cycle
of the NHSC, which will begin in the fall
of 2004. They represent the best score
results that could be obtained at this
time with nationally available data. The
scores are displayed in Automatic
Score Facilities List (Excel/.xls)
which contains a separate spreadsheet
for each category of entity or population.
Any site that is located in a regularly
designated HPSA can continue to use the
HPSA score for that area/population group,
which is likely to be much higher than
the automatic HPSA scores presented here.
This also applies to individual sites
that are part of a multi-site FQHC Grantee
or FQHCLA Entity HPSA; if any individual
site is in a geographic or population
group HPSA, or has been designated as
a Facility HPSA using the regular process,
that site may use that HPSA’s score
for recruitment purposes. However, other
sites of the same entity must use the
entity automatic score.
Possible
Score Appeals
It is important to keep the automatic
scoring issue in context and not overemphasize
its importance. There are only four programs
which use the HPSA score to allocate resources:
the NHSC Scholarship and Loan Repayment
Programs, the NHSC Ready Responders Program,
and the portion of the Federal J1 Visa
Waiver program administered by HHS. In
the case of the NHSC Loan Repayment Program,
which has the largest pool of clinicians
in this group of programs, contracts are
approved in descending order of the HPSA
score of the site involved, but we project
that, similar to last year, even applicants
from sites with no scores will likely
be funded. The other three programs require
that certain minimum HPSA score thresholds
be exceeded for the site to be considered;
however, these programs are very small
in terms of the number of clinicians available.
Most J1 Visa Waiver physicians are placed
not by HHS but through the State Conrad
30 programs, which are not subject to
the scoring restrictions. Therefore, the
HPSA score should have a limited impact
on recruitment opportunities for most
entities.
There are many FQHCs and RHCs in geographic
or population group HPSAs with scores
that exceed the thresholds for these programs;
and there are already more requests to
fill vacancies from qualifying entities
than there are NHSC Scholars or J1 Visa
Waiver physicians or Ready Responders
available. Adding more high scoring HPSAs
through attempting to adjust upward the
automatic HPSA score will only result
in increasing competition among safety
net providers for increasingly scarcer
resources. Much more can be gained through
focusing on loan repayment and cultivating
other recruitment resources, such as linking
to training programs, or the use of nurse
practitioners, physician assistants, and
nurse midwives, for whom the role of HPSA
scores is less significant. It is unlikely
that major changes to the automatic scores
shown in Automatic
Score Facilities List (Excel/.xls)
(Excel/.xls) can be made without significant
effort, and the payoff is not likely to
be significant.
However, there may be some instances
where use of local data can improve the
HPSA score. Requests for revision of an
entity’s HPSA score must be reviewed
by the Shortage Designation Branch. To
avoid overwhelming the designation process,
appeals for reconsideration should be
pursued only in critical cases where the
resulting score improvement will make
a very significant difference in eligibility
for resources
The scoring criteria in Criteria
for Determining Primary Care HPSAs of
Greatest Shortage should be used for
reference if appeals are being considered,
to see what if any difference new data
might make in the score.
If an entity wishes to submit alternative
data for use in the scoring process, the
following guidelines are provided:
Population Data and Poverty
Data: US Census data on these
variables should be used for any service
area considered: data on these variables
may be calculated for the actual service
area rather than the whole county or
PCSA of the entity’s location,
if a more accurate definition of the
actual service area is available. If
FQHC grantees have updated UDS poverty
data that are significantly different
from that of 2002, they may be helpful.
(Please note that the majority of the
FQHC grantee sites already get the maximum
points allowed for the poverty variable,
based on UDS user poverty rates greater
than 50 %.) If FQHC Look-Alikes or RHCs
have data on the poverty rates of their
users comparable to UDS data for FQHC
grantees, such data may be submitted
and will be considered.
Infant Mortality Rate/Low Birth
Weight: in most cases, county-level
data are the only data available for
these birth outcome variables. In urban
areas, it may be possible to get more
specific data for portions of the county;
in order to use such sub-county data,
there must be at least 4000 births in
the area over a 5-year period. An alternative
is to provide racially adjusted IMR/LBW
if the area under consideration has
a significantly higher population of
one racial or ethnic group than the
county as a whole. (Please note that
most facilities received no points for
this factor in the computed automatic
score, and it is unlikely that any facility
will get more than 1 or 2 points maximum
with new data.)
Provider data: all
non-federal providers without NHSC obligations
or J1 visa waiver obligations must be
counted under the current designation
and HPSA scoring method. No FTE adjustments
were made in the national data used
in automatic scoring, and no effort
was made to “back out” physicians
in the NHSC or on J-1 waivers, so there
may be some data available locally that
could affect the total provider count
for scoring purposes
Travel Time/Distance:
these estimates were based on use of
PCSA data and GIS road classification
data. In some cases, they may not accurately
reflect the actual time/distance to
nearest source of care for the population
being reviewed. Local data could be
submitted in accordance with the existing
HPSA regulations.
We encourage entities interested in improving
their scores to work with the Primary
Care Offices (PCOs); they have extensive
knowledge and experience with the HPSA
process and can help assess the likelihood
of significant improvements in scores
based on use of any of the various options
listed above. Many Primary Care Associations
(PCAs) also have experience and expertise
with designations and can assist in this
scoring process. A coordinated approach
within a State, using a consistent methodology
for any proposed rescoring of multiple
sites, is urged in order to reduce the
number of appeal requests that will not
significantly change the outcome and minimize
the time required for processing successful
appeals.
Criteria for
Determining Primary Care HPSAs of Greatest
Shortage
(Note: GE is defined as greater than or
equal to)
1. Score for
population-to-full-time-equivalent primary
care physician (PCP) ratio
Ratio > 10,000:1, or No
PCPs and Population GE 2500 |
5 points |
10,000:1 > Ratio GE 5,000:1,
or No PCPs and Population GE 2000 |
4 points |
5,000:1 > Ratio GE 4,000:1,
or No PCPs and Population GE 1500 |
3 points |
4,000:1 > Ratio GE 3,500:1,
or No PCPs and Population GE 1000 |
2 points |
3,500:1 > Ratio GE 3,000:1,
or No PCPs and Population GE 500 |
1 point |
These points are doubled in calculating
the final score.
2. Score for
percent of population with incomes below
poverty level (P)
P GE 50% |
5 points |
50% > P GE 40% |
4 points |
40% > P GE 30% |
3 points |
30% > P GE 20% |
2 points |
20% > P GE 15% |
1 point |
P < 15% |
0 points |
3. Infant
Health Index
IMR GE 20 or
LBW GE 13 |
5 points |
20>IMR>18 or 13>LBW>11 |
4 points |
18>IMR>15 or 11>LBW>10 |
3 points |
15>IMR>12 or 10>LBW>
9 |
2 points |
12>IMR>10 or 9>LBW>
7 |
1 point |
IMR<20 or LBW< 7 |
0 points |
4. Score
for travel distance/time to nearest source
of accessible care outside the HPSA
(Nearest Source of Care is defined as
the closest location where the residents
of the area or population that is designated
have access to comprehensive primary care
services.)
Time GE 60 minutes
or Distance GE 50 miles |
5 points |
60 min > Time GE 50 min
or 50 mi > Dist GE 40 mi |
4 points |
50 min > Time GE 40 min
or 40 mi > Dist GE 30 mi |
3 points |
40 min > Time GE 30 min
or 30 mi > Dist GE 20 mi |
2 points |
30 min > Time GE 20 min
or 20 mi > Dist GE 10 mi |
1 point |
Time < 20 min or Distance
< 10 mi |
0 points |
Questions: Please
phone 301-594-0816 to speak to
the appropriate area analyst. Please keep
in mind that continuing submissions of
HPSA designation requests, and of MUA/P
requests related to new starts, are being
processed as well. |