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Automatic Facility HPSA Scoring

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 below), 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 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.  If the facility is located in a regular (geographic or population HPSA), the ratio for that HPSA is used in the formula instead.

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 and now LALs, the most recent UDS-reported data on percent of users with incomes below 100% of poverty were used. For RHCs, the 2009 Claritas poverty estimates for the county of location were used. Incomplete data on user income levels will limit the impact of this factor for FQHCs and LALs that do not report complete data.
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.

General Comments

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 same process outlined above was applied to the dental and mental health HPSAs as well, using comparable data sources appropriate to the discipline.

All of the FQHCS, LALs, RHCs, and IHS, Tribal, and Urban Indian sites whose name and address has been transmitted to the Office of Shortage Designation are added to the HPSA file and posted on-line as soon as receive the information.  The site and the initial score will be posted on HPSA Find at http://www.hpsafind.hrsa.gov, where it can be searched by state and county. For multi-site entities, the HPSA is listed under the name of the grantee or LAL and listed under the county in which the main site is located.  

Individual satellites will not be listed separately as the HPSA applies to the whole entity.

Applicability of Automatic HPSA Scores

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 original automatic HPSA scores. 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 Updates

It is important to keep the automatic scoring issue in context and not have unrealistic expectations of increasing scores. 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 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. Equal attention should be paid to other important recruitment and retention resources, such as linking to training programs.  It is unlikely that major changes to the automatic scores and the payoff may not be significant.

However, there some sites have been able to increase their scores in instances where use of local data were provided. Requests for revision of an entity’s HPSA score must be reviewed by the Office of Shortage Designation. To avoid overwhelming the designation process, requests for score updates 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 this document should be used for reference if appeals are being considered, to see what if any difference new data might make in the score.

Auto HPSA Scoring Updates

If an entity wishes to submit alternative data for use in the scoring process, the following guidelines are provided:

Population Data and Poverty Data

U.S. 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 wholecounty or PCSA of the entity’s location, if a more accurate definition of the actual service area is available. If FQHC grantees and LALs have updated UDS poverty data that are significantly different from previous years, 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 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.  It is also an option to provide a ratio for the low income population in an area, similar to the Low Income HPSA designation process, which counts the FTEs available to residents below 200% of poverty by measuring available services through Medicaid and sliding fee scale.  This requires significantly more effort to determine.
If the FQHC is located in a geographic or population HPSA, the ratio for that HPSA can be substituted in the scoring for the auto HPSA; the match was not done at the first scoring but can be done upon request or submission of the information.

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 encouraged in order to reduce the number of scoring 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)

Score for population-to-full-time-equivalent primary care physician (PCP) ratio
Ratio > 10,000:1, or No PCPs and Population GE 25005 points
10,000:1 > Ratio GE 5,000:1, or No PCPs and Population GE 20004 points
5,000:1 > Ratio GE 4,000:1, or No PCPs and Population GE 15003 points
4,000:1 > Ratio GE 3,500:1, or No PCPs and Population GE 10002 points
3,500:1 > Ratio GE 3,000:1, or No PCPs and Population GE 5001 point
These points are doubled in calculating the final score.

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


Infant Health Index
IMR GE 20 or LBW GE 135 points
20>IMR>18 or 13>LBW>114 points
18>IMR>15 or 11>LBW>103 points
15>IMR>12 or 10>LBW> 92 points
12>IMR>10 or 9>LBW> 71 point
IMR<10 or LBW< 70 points


Score for travel distance/time to nearest source of accessible care outside the HPSA
Time GE 60 minutes or Distance GE 50 miles5 points
60 min > Time GE 50 min or 50 mi > Dist GE 40 mi4 points
50 min > Time GE 40 min or 40 mi > Dist GE 30 mi3 points
40 min > Time GE 30 min or 30 mi > Dist GE 20 mi2 points
30 min > Time GE 20 min or 20 mi > Dist GE 10 mi1 point
Time < 20 min or Distance < 10 mi0 points

(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.)

 

Criteria for Determining Dental Care HPSAs of Greatest Shortage

(Note: GE is defined as greater than or equal to)

Score for population-to-full-time-equivalent primary care physician (PCP) ratio
Ratio > 10,000:1, or No DDs and Population GE 30005 points
10,000:1 > Ratio GE 8,000:1, or No DDs and Population GE 25004 points
8,000:1 > Ratio GE 6,000:1, or No DDs and Population GE 20003 points
6,000:1 > Ratio GE 5,000:1, or No DDs and Population GE 15002 points
5,000:1 > Ratio GE 4,000:1, or No DD and Population GE 10001 point
These points are doubled in calculating the final score.


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
These points are doubled in calculating the final score.


Score for travel distance/time to nearest source of accessible care outside the HPSA
Time GE 90 minutes or Distance GE 60 miles5 points
90 min > Time GE 75 min or 60 mi > Dist GE 50 mi4 points
75 min > Time GE 60 min or 50 mi > Dist GE 40 mi3 points
60 min > Time GE 45 min or 40 mi > Dist GE 30 mi2 points
45 min > Time GE 30 min or 30 mi > Dist GE 20 mi1 point
Time < 20 min or Distance < 10 mi0 points

(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.)


Percent of Population with Access to Fluoridated Water
< 50%1 point
> 50%0 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 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 RatioCore Mental Health RatioScore
GT 45,000:0 ANDGT 4,500:08
 GT 4500:1 and LT 6000:17
LT 20,000:1 and GT 15,000:1 ANDGT 6000:1 and LT <9,000:16
LT 30,000:1 and GT 15,000:1 ORGT 4,500:1 and LT 6,000:15
LT 45,000:1 and GT  20,000:1 ANDGT 4,500:0 and LT 6,000:04
GT 20,000:1 ANDGT 6,000:13
GT 30,000:1 2
 GT 9,000:11


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


Score for travel distance/time to nearest source of accessible care outside the HPSA
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

(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.)

2. Scores for Additional Factors  

Youth Ratio: Ratio of Children under 18 to Adults 18-64
>60%3 points
<60 and >402 points
<40 and >201 point
Elderly Ratio: Ratio of Adults over 65 to Adults 18-64
>25%3 points
<25 and >152 points
<15 and >101 point
Substance Abuse prevalence: Area’s rate is in worst quartile for nation/region/or state
Yes1 point
No0 points
Alcohol Abuse prevalence: Area’s rate is in worst quartile for nation/region/or state
Yes1 point
No0 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.  

Questions? Contact Norma Campbell. Submission of alternative data in an e-mail attachment based on the information in this document is the most efficient way to request a score update.