[Federal Register Volume 68, Number 104 (Friday, May 30, 2003)]
[Notices]
[Pages 32531-32533]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 03-13478]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration


Criteria for Determining Priorities Among Health Professional 
Shortage Areas

AGENCY: Health Resources and Services Administration, HHS.

ACTION: Notice.

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SUMMARY: In accordance with the requirements of section 333A(b)(1) of 
the Public Health Service (PHS) Act, as amended by the Health Care 
Safety Net Amendments of 2002, 42 U.S.C. 254f-1(b)(1), the Secretary of 
HHS shall establish the criteria which he will use to make 
determinations under section 333A(a)(1)(A) of the health professional 
shortage areas (HPSAs) with the greatest shortages. This notice sets 
forth the current greatest shortage criteria for primary care,dental 
and mental health HPSAs, which will be used pending the adoption of new 
criteria through rulemaking.

EFFECTIVE DATE: May 30, 2003.

FOR FURTHER INFORMATION CONTACT: Andy Jordan, Acting Chief, Shortage 
Designation Branch, National Center for Health Workforce Analysis, 
Bureau of Health Professions, Health Resources and Services 
Administration, 5600 Fishers Lane, Parklawn Building, Room 8C-26, 
Rockville, Maryland 20857, (301-594-0816).

SUPPLEMENTARY INFORMATION: Section 332 of the PHS Act, 42 U.S.C. 254e, 
provides that the Secretary shall designate HPSAs based on criteria 
established by regulation. HPSAs are defined in section 332 to include 
(1) urban and rural geographic areas with shortages of health 
professionals, (2) population groups with such shortages, and (3) 
facilities with such shortages. The required regulations setting forth 
the criteria for designating HPSAs are codified at 42 CFR Part 5.

[[Page 32532]]

    Section 333A(a)(1)(A) of the PHS Act requires that the Secretary 
give priority in assignment of NHSC personnel to entities serving HPSAs 
with the greatest health professional shortage. Section 333A(c) of the 
PHS Act requires that the Secretary establish criteria specifying the 
manner in which he determines HPSAs of greatest shortage and published 
in the Federal Register.
    The Secretary is developing a new method for designating HPSAs and 
determining HPSAs of greatest shortage. A Notice of Proposed Rulemaking 
(NPRM), relating to primary care HPSAs, was initially published in 
1998. Major revisions were made in response to the comments received, 
and the Secretary anticipates publishing a new NPRM this year. 
Subsequent to the adoption of a new rule relating to primary care 
HPSAs, the Secretary intends to propose new methods for designating 
dental care and mental health care HPSAs and to publish new criteria 
for determining HPSAs of greatest shortage for primary care, dental 
care and mental health care HPSAs. In the interim, to determine HPSAs 
of greatest shortage, the Secretary will continue to use the current 
criteria set forth in this notice.

Approach for Determining Greatest Shortages

    1. Three factors (population-to-provider ratio, poverty rate, and 
travel distance/time to nearest accessible source of care) are 
applicable to all categories of HPSAs (primary care, dental and mental 
health).
    2. Additional factors specifically related to each HPSA category 
are included (e.g., infant mortality/low birth weight rates (IMR/LBW) 
for primary care; presence of fluoridated water for dental; ratios of 
the population under 18 and over 65 and the prevalence of alcohol or 
substance abuse for mental health).
    3. A scale is developed for scoring each factor. The scale 
generally includes five scoring levels, and reflects different patient 
utilization patterns for primary care, dental and mental health 
services.
    4. Relative weights for the various factors are established, based 
on the significance of the factors in determining a shortage.
    5. Each HPSA is scored on each factor.
    6. The factor scores are weighted and summed for each HPSA.
    7. The total scores for each HPSA are ranked from highest to lowest 
for each HPSA category.
    8. A level is selected annually to identify the boundary between 
the HPSAs of greatest shortage and all other HPSAs.
    9. Those HPSAs with total scores equal to or greater than the 
selected boundary level within each category are identified as the 
HPSAs of greatest shortage.

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  3,000:1, or No PCPs and 
Population GE 500 = 1 point.

    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;
20IMR18 OR 13LBW11 = 4 
points;
18IMR15 or 11LBW10 = 3 
points;
15IMR12 or 10LBW9 = 2 
points;
12IMR10 or 9LBW7 = 1 point;
IMR<10 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 Dist < 10 mi = 0 points.

Criteria for Determining Dental HPSAs of Greatest Shortage

    1. Score for population-to-full-time-equivalent provider ratio:

Ratio GE 10,000:1, or no dentists and population GE 3,000 = 5 points;
10,000:1  Ratio GE 8,000:1, or no dentists and population GE 
2,500 = 4 points;
8,000:1  Ratio GE 6,000:1, or no dentists and population GE 
2,000 = 3 points;
6,000:1  Ratio GE 5,000:1, or no dentists and population GE 
1,500 = 2 points;
5,000:1  Ratio GE 4,000:1, or no dentists and population GE 
1,000 = 1 point.

    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. 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 
dental care services.

Time GE 90 minutes or Distance GE 60 miles = 5 points;
90 min  Time GE 75 min or 60 mi  Dist GE 50 mi = 
4 points;
75 min  Time GE 60 min or 50 mi  Dist GE 40 mi = 
3 points;
60 min  Time GE 45 min or 40 mi  Dist GE 30 mi = 
2 points;
45 min  Time GE 30 min or 30 mi  Dist GE 20 mi = 
1 point;
Time < 30 min or Dist < 20 mi = 0 points.

    4. Score for Fluoridation:

Fluoridated Water Available for =50% of Population = 0 
points;
Fluoridated Water Available for <50% of Population = 1 point.

    For primary care and dental care HPSAs, the population-to-
practitioner ratio is double weighted, as it is a primary factor in the 
designation of HPSAs under section 332 of the PHS Act. The poverty rate 
is also doubled. The poverty rate is widely acknowledged in 
professional literature as a key measure of need for primary health 
services, and income levels have been shown to correlate directly with 
access to health care and with health status measures. This results in 
a maximum possible score of 26 points.

Criteria for Determining Mental Health HPSAs of Greatest Shortage

    1. Score for population-to-full-time-equivalent provider ratio:
    The reporting of the number of psychiatrists present is required in 
all mental health HPSA applications; the

[[Page 32533]]

reporting of other mental health professionals is optional. Other 
mental health professionals include: clinical psychologists, clinical 
social workers, marriage and family therapists, and psychiatric nurse 
specialists. Depending upon the data reported, the scales utilize a 
population-to-psychiatrist ratio and/or a population-to-core mental 
health provider ratio. (Core mental health providers include 
psychiatrists and other mental health professionals.) The table below 
defines the various provider to population ratios and related scores:

------------------------------------------------------------------------
          Psychiatrist ratio           Core mental health ratio   Score
------------------------------------------------------------------------
GT 45,000:0 and......................  GT 4,500:0..............        8
                                       GT 4500:1 and LT 6000:1.        7
LT 20,000:1 and GT 15,000:1 and......  GT 6000:1 and LT                6
                                        <9,000:1.
LT 30,000:1 and GT 15,000:1 or.......  GT 4,500:1 and LT               5
                                        6,000:1.
LT 45,000:1 and GT 20,000:1 and......  GT 4,500:0 and LT               4
                                        6,000:0.
GT 20,000:1 and......................  GT 6,000:1..............        3
GT 30,000:1..........................  ........................        2
                                       GT 9,000:1..............        1
------------------------------------------------------------------------

    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. 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 
mental health care services.

Time GE 60 minutes = 5 points;
<60 min and 50 minutes = 4 points;
<50 minutes and 40 minutes = 3 points;
<40 minutes and 30 minutes = 2 points;
<30 minutes and 20 minutes = 1 point.

    4. Scores for Additional Factors

    (a) Youth Ratio: Ratio of Children under 18 to Adults 18-64:

=60% = 3 points;
<60 and 40 = 2 points;
<40 and 20 = 1 point.

    (b) Elderly Ratio: Ratio of Adults over 65 to Adults 18-64

=25% = 3 points;
<25 and 15 = 2 points;
<15 and 10 = 1 point.

    (c) Substance Abuse prevalence: Area's rate is in worst quartile 
for nation/region/or state:

Yes = 1 point;
No = 0 points.

    (d) Alcohol Abuse prevalence: Area's rate is in worst quartile for 
nation/region/or state:

Yes = 1 point;
No = 0 points.

    Since a larger number of factors are considered in the mental 
health HPSA scoring methodology, there is no doubling of the weights. 
The possible points for the population to provider ratio, 8, is greater 
than for any of the other factors, in recognition of its primary 
importance as mentioned above. The maximum score is 26.

Facility HPSA Scores

    All geographic and population group HPSAs are scored using the 
above methodologies. In general, public or nonprofit private facilities 
designated as HPSAs based on the provision of services to a geographic 
or population group HPSA receive the score of the HPSA they serve. The 
exception is for Federally Qualified Health Centers and Rural Health 
Centers which are automatically designated under the Health Care Safety 
Net Amendments of 2002. These facilities will be scored as an entity, 
using the same factors used for the designation of areas and 
populations described above, but applied to the entity itself. 
Designated facilities which serve interned populations (Federal and 
State correctional facilities and State/county mental hospitals) are 
designated based on internee/inpatient data that differs from the data 
used in geographic and population group HPSAs. Poverty rate and travel 
distance/time to nearest accessible source of care are not data 
reported or required under the facility HPSA designation criteria and, 
likewise, do not appear to be directly applicable in determining HPSA 
scores for these institutionalized populations.
    Consequently, correctional facility/mental hospital HPSA scores are 
extrapolated from the degree-of-shortage (DOS) groups determined in the 
HPSA designation process. See 42 CFR part 5, Appendices A, B and C. The 
determination of DOS groups for these facilities is based primarily on 
internee/inpatient-to-provider ratios, which is similar to the first 
factor used for determining HPSAs of greatest shortage (population-to-
provider ratio).
    For all correctional facilities, the following scores apply: DOS 
group 1 = 21, DOS group 2 = 15, and DOS group 3 = 9. These were derived 
by dividing the HPSA score range (1-25) into quartiles, then setting 
the HPSA score at the midpoints, respectively. Correctional facilities 
only have DOS 1-3, so the midpoints for the top three quartiles were 
used. For State and county mental hospitals, this approach was adjusted 
due to the different distribution of mental health facilities among the 
DOS groups , with DOS group 1 = 20, DOS group 2 = 16, DOS group 3 = 12, 
and DOS group 4 = 8.
    Paperwork Reduction Act: The criteria used to make determinations 
under section 333A(a)(1)(A) of the health professional shortage areas 
(HPSAs) with the greatest shortages described in this announcement will 
not involve data collection activities that fall under the purview of 
the Paperwork Reduction Act of 1995. If the methods for determining 
health professional shortage area with the greatest shortages fall 
under the purview of the Paper work Reduction Act, the Program will 
assist HRSA in seeking OMB clearance for proposed data collection 
activities.

    Dated: May 22, 2003.
Elizabeth M. Duke,
Administrator.
[FR Doc. 03-13478 Filed 5-29-03; 8:45 am]
BILLING CODE 4165-15-P