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HPSA Designation Criteria
for Primary Medical Care
Also see:
Part I -- Geographic Areas
A. Criteria.
A geographic area will be designated as having
a shortage of primary medical care professionals if the following three criteria
are met:
1. The area is a rational area for the delivery
of primary medical care services.
2. One of the following conditions prevails within
the area:
(a) The area has a population to full-time-equivalent
primary care physician ratio of at least 3,500:1.
(b) The area has a population to full-time-equivalent
primary care physician ratio of less than 3,500:1 but greater than 3,000:1 and
has unusually high needs for primary care services or insufficient capacity
of existing primary care providers.
3. Primary medical care professionals in contiguous
areas are overutilized, excessively distant, or inaccessible to the population
of the area under consideration.
B. Methodology.
In determining whether an area meets the criteria
established by paragraph A of this part, the following methodology will be used:
1. Rational Areas for the Delivery of Primary
Medical Care Services.
(a) The following areas will be considered rational
areas for the delivery of primary medical care services:
(i) A county, or a group of contiguous counties
whose population centers are within 30 minutes travel time of each other.
(ii) 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.
(iii) Established neighborhoods and communities
within metropolitan areas which display a strong self-identity (as indicated
by a homogeneous socioeconomic or demographic structure and/or a tradition of
interaction or interdependency), have limited interaction with contiguous areas,
and which, in general, have a minimum population of 20,000.
(b) The following distances will be used as guidelines
in determining distances corresponding to 30 minutes travel time:
(i) Under normal conditions with primary roads
available: 20 miles.
(ii) In mountainous terrain or in areas with only
secondary roads available: 15 miles.
(iii) In flat terrain or in areas connected by
interstate highways: 25 miles.
Within inner portions of metropolitan areas, information
on the public transportation system will be used to determine the distance corresponding
to 30 minutes travel time.
2. Population Count.
The population count used will be the total permanent
resident civilian population of the area, excluding inmates of institutions
with the following adjustments, where appropriate:
(a) The effect of transient populations on the
need of an area for primary care professional(s) will be taken into account
as follows:
(i) Seasonal residents, i.e., those who maintain
a residence in the area but inhabit it for only 2 to 8 months per year, may
be included but must be weighted in proportion to the fraction of the year they
are present in the area.
(ii) Other tourists (non-resident) may be included
in an area's population but only with a weight of 0.25, using the following
formula: Effective tourist contribution to population = 0.25 x (fraction of
year tourists are present in area) x (average daily number of tourists during
portion of year that tourists are present).
(iii) Migratory workers and their families may
be included in an area's population, using the following formula: Effective
migrant contribution to population = (fraction of year migrants are present
in area) x (average daily number of migrants during portion of year that migrants
are present).
3. Counting of Primary Care Practitioners.
(a) All non-Federal doctors of medicine (M.D.)
and doctors of osteopathy (D.O.) providing direct patient care who practice
principally in one of the four primary care specialities -- general or family
practice, general internal medicine, pediatrics, and obstetrics and gynecology
-- will be counted. Those physicians engaged solely in administration, research,
and teaching will be excluded. Adjustments for the following factors will be
made in computing the number of full-time-equivalent (FTE) primary care physicians:
(i) Interns and residents will be counted as 0.1
full-time equivalent (FTE) physicians.
(ii) Graduates of foreign medical schools who are
not citizens or lawful permanent residents of the United States will be excluded
from physician counts.
(iii) Those graduates of foreign medical schools
who are citizens or lawful permanent residents of the United States, but do
not have unrestricted licenses to practice medicine, will be counted as 0.5
FTE physicians.
(b) Practitioners who are semi-retired, who operate
a reduced practice due to infirmity or other limiting conditions, or who provide
patient care services to the residents of the area only on a part-time basis
will be discounted through the use of full-time equivalency figures. A 40-hour
work week will be used as the standard for determining full-time equivalents
in these cases. For practitioners working less than a 40-hour week, every four
(4) hours (or 1/2 day) spent providing patient care, in either ambulatory or
inpatient settings, will be counted as 0.1 FTE (with numbers obtained for FTE's
rounded to the nearest 0.1 FTE), and each physician providing patient care 40
or more hours a week will be counted as 1.0 FTE physician. (For cases where
data are available only for the number of hours providing patient care in office
settings, equivalencies will be provided in guidelines.)
(c) In some cases, physicians located within an
area may not be accessible to the population of the area under consideration.
Allowances for physicians with restricted practices can be made, on a case-by-case
basis. However, where only a portion of the population of the area cannot access
existing primary care resources in the area, a population group designation
may be more appropriate (see part II of this appendix).
(d) Hospital staff physicians involved exclusively
in inpatient care will be excluded. The number of full-time equivalent physicians
practicing in organized outpatient departments and primary care clinics will
be included, but those in emergency rooms will be excluded.
(e) Physicians who are suspended under provisions
of the Medicare-Medicaid Anti-Fraud and Abuse Act for a period of eighteen months
or more will be excluded.
4. Determination of Unusually High Needs for
Primary Medical Care Services.
An area will be considered as having unusually
high needs for primary health care services if at least one of the following
criteria is met:
(a) The area has more than 100 births per year
per 1,000 women aged 15 - 44.
(b) The area has more than 20 infant deaths per
1,000 live births.
(c) More than 20% of the population (or of all
households) have incomes below the poverty level.
5. Determination of Insufficient Capacity of
Existing Primary Care Providers.
An area's existing primary care providers will
be considered to have insufficient capacity if at least two of the following
criteria are met:
(a) More than 8,000 office or outpatient visits
per year per FTE primary care physician serving the area.
(b) Unusually long waits for appointments for routine
medical services (i.e., more than 7 days for established patients and 14 days
for new patients).
(c) Excessive average waiting time at primary care
providers (longer than one hour where patients have appointments or two hours
where patients are treated on a first-come, first-served basis).
(d) Evidence of excessive use of emergency room
facilities for routine primary care.
(e) A substantial proportion (2/3 or more) of the
area's physicians do not accept new patients.
(f) Abnormally low utilization of health services,
as indicated by an average of 2.0 or less office visits per year on the part
of the area's population.
6. Contiguous Area Considerations.
Primary care professional(s) in areas contiguous
to an area being considered for designation will be considered excessively distant,
overutilized or inaccessible to the population of the area under consideration
if one of the following conditions prevails in each contiguous area:
(a) Primary care professional(s) in the contiguous
area are more than 30 minutes travel time from the population center(s) of the
area being considered for designation (measured in accordance with paragraph
B.1(b) of this part).
(b) The contiguous area population-to-full-time-equivalent
primary care physician ratio is in excess of 2000:1, indicating that practitioners
in the contiguous area cannot be expected to help alleviate the shortage situation
in the area being considered for designation.
(c) Primary care professional(s) in the contiguous
area are inaccessible to the population of the area under consideration because
of specified access barriers, such as:
(i) Significant differences between the demographic
(or socio-economic) characteristics of the area under consideration and those
of the contiguous area, indicating that the population of the area under consideration
may be effectively isolated from nearby resources. This isolation could be indicated,
for example, by an unusually high proportion of non-English-speaking persons.
(ii) A lack of economic access to contiguous area
resources, as indicated particularly where a very high proportion of the population
of the area under consideration is poor (i.e., where more than 20 percent of
the population or the households have incomes below the poverty level), and
Medicaid-covered or public primary care services are not available in the contiguous
area.
Part II -- Population Groups
A. Criteria.
1. In general, specific population groups within
particular geographic areas will be designated as having a shortage of primary
medical care professional(s) if the following three criteria are met:
(a) The area in which they reside is rational for
the delivery of primary medical care services, as defined in paragraph B.1 of
part I of this appendix.
(b) Access barriers prevent the population group
from use of the area's primary medical care providers. Such barriers may be
economic, linguistic, cultural, or architectural, or could involve refusal of
some providers to accept certain types of patients or to accept Medicaid reimbursement.
(c) The ratio of the number of persons in the population
group to the number of primary care physicians practicing in the area and serving
the population group is at least 3,000:1.
2. Indians and Alaska Natives will be considered
for designation as having shortages of primary care professional(s) as follows:
(a) Groups of members of Indian tribes (as defined
in section 4(d) of Pub. L. 94 - 437, the Indian Health Care Improvement Act
of 1976) are automatically designated.
(b) Other groups of Indians or Alaska Natives (as
defined in section 4(c) of Pub. L. 94 - 437) will be designated if the general
criteria in paragraph A are met.
Part III -- Facilities
A. Federal and State Correctional Institutions.
1. Criteria.
Medium to maximum security Federal and State correctional
institutions and youth detention facilities will be designated as having a shortage
of primary medical care professional(s) if both the following criteria are met:
(a) The institution has at least 250 inmates.
(b) The ratio of the number of internees per year
to the number of FTE primary care physicians serving the institution is at least
1,000:1.
Here the number of internees is defined as follows:
(i) If the number of new inmates per year and the
average length-of-stay (ALOS) are not specified, or if the information provided
does not indicate that intake medical examinations are routinely performed upon
entry, then -- Number of internees = average number of inmates.
(ii) If the ALOS is specified as one year or more,
and intake medical examinations are routinely performed upon entry, then --
Number of internees = average number of inmates + (0.3) x number of new inmates
per year.
(iii) If the ALOS is specified as less than one
year, and intake examinations are routinely performed upon entry, then -- Number
of internees = average number of inmates + (0.2) x (1+ALOS/2) x number of new
inmates per year where ALOS = average length-of-stay (in fraction of year).
(The number of FTE primary care physicians is computed as in part I, section
B, paragraph 3 above.)
B. Public or Non-Profit Medical Facilities.
1. Criteria.
Public or non-profit private medical facilities
will be designated as having a shortage of primary medical care professional(s)
if:
(a) the facility is providing primary medical care
services to an area or population group designated as having a primary care
professional(s) shortage; and
(b) the facility has insufficient capacity to meet
the primary care needs of that area or population group.
2. Methodology
In determining whether public or nonprofit private
medical facilities meet the criteria established by paragraph B.1 of this Part,
the following methodology will be used:
(a) Provision of Services to a Designated Area
or Population Group.
A facility will be considered to be providing services
to a designated area or population group if either:
(i) A majority of the facility's primary care services
are being provided to residents of designated primary care professional(s) shortage
areas or to population groups designated as having a shortage of primary care
professional(s); or
(ii) The population within a designated primary
care shortage area or population group has reasonable access to primary care
services provided at the facility. Reasonable access will be assumed if the
area within which the population resides lies within 30 minutes travel time
of the facility and non-physical barriers (relating to demographic and socioeconomic
characteristics of the population) do not prevent the population from receiving
care at the facility.
Migrant health centers (as defined in section 319(a)(1)
of the Act) which are located in areas with designated migrant population groups
and Indian Health Service facilities are assumed to be meeting this requirement.
(b) Insufficient capacity to meet primary care
needs.
A facility will be considered to have insufficient
capacity to meet the primary care needs of the area or population it serves
if at least two of the following conditions exist at the facility:
(i) There are more than 8,000 outpatient visits
per year per FTE primary care physician on the staff of the facility. (Here
the number of FTE primary care physicians is computed as in Part I, Section
B, paragraph 3 above.)
(ii) There is excessive usage of emergency room
facilities for routine primary care.
(iii) Waiting time for appointments is more than
7 days for established patients or more than 14 days for new patients, for routine
health services.
(iv) Waiting time at the facility is longer than
1 hour where patients have appointments or 2 hours where patients are treated
on a first-come, first-served basis.
Relevant excerpts from 42 Code of Federal Regulations (CFR), Chapter 1, Part 5, Appendix A (October 1, 1993, pp. 34-48)
Criteria for Designation of Areas Having Shortages of Primary Medical Care Professionals [45 FR 76000, Nov. 17, 1980, as amended at 54
FR 8737, Mar. 2, 1989; 57 FR 2480, Jan. 22, 1992]
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