Health Professional Shortage Area Scoring Criteria Request for Information (RFI)

Action: Request for Information: Health Professional Shortage Area (HPSA) Scoring Criteria
Summary: The Health Resources and Services Administration (HRSA) seeks public input and feedback to inform policy considerations related to changes to scoring criteria for Health Professional Shortage Areas, as described in this Request for Information (RFI), and to solicit additional ideas and suggestions from the public.
Date: 5/21/2020

I. Overview of this RFI

Section 332 of the Public Health Service Act, 42 U.S.C. § 254e authorizes HRSA’s shortage designation activities. Under this authority, HRSA designates geographic areas, population groups within geographic areas, and certain facilities as HPSAs. Per statute1 and regulation2 , HRSA assesses three types of HPSAs by discipline: primary care, dental health, and mental health. After a HPSA is designated, it receives a score according to established criteria. 

Three factors are currently used in scoring criteria for all disciplines: (1) population-to-provider ratio; (2) poverty rate; and (3) travel distance/time to the nearest accessible source of care. Other factors are discipline-specific. Specifically:

  • primary care scores incorporate rates of infant mortality or low birth weight;
  • dental health scores incorporate the availability of fluoridated water;
  • mental health scores incorporate the ratios of the population under the age of 18 and over the age of 65 to the adult population ages 18 to 64, as well as the prevalence of alcohol and substance use disorder.3

HPSA scores currently range from 0-25 for primary care and mental health, and 0-26 for dental health. A higher HPSA score is intended to demonstrate a greater the level of need in the area, population, or facility subject to the designation. As of December 31, 2019, there were 7,655 primary care, 6,820 dental health, and 6,117 mental health HPSAs in the United States. While several federal programs now use HPSAs to determine eligibility for federal resources, HPSAs were developed to distribute National Health Service Corps (NHSC) providers to areas, populations, and facilities with the greatest need. Since its inception in 1972, the NHSC has worked to support qualified health care providers dedicated to working in underserved communities in urban, rural, and tribal areas. The NHSC provides loan repayment awards to eligible health providers, as well as scholarships to students, in return for commitments to serve in NHSC-approved sites located in HPSAs. 

HRSA recognizes the importance of equitably, impartially, and transparently scoring HPSAs to reflect relative need. HRSA has issued this RFI to solicit broad stakeholder feedback regarding current HPSA scoring criteria and possible future approaches.

For more information on current HPSA scoring, including point totals for each discipline.

II. Solicitation of feedback

HRSA is seeking input from the public on considerations that may inform HRSA’s future decisions regarding changes that could be made to HPSA scoring criteria. 

The purpose of this RFI is two-fold. First, HRSA seeks stakeholder input regarding current scoring found in a notice published in the Federal Register, 68 Fed. Reg. 32531 (May 30, 2003). Second, HRSA seeks stakeholder input on possible additions or alternative approaches to HPSA scoring. These would include, but are not limited to, new factors, components, or point weighting. HRSA will not accept proposals to expand NHSC eligibility to new provider types or proposals that otherwise go beyond the purview of HPSA scoring. This RFI will not be used to change or amend statutory language found in section 332 of the PHSA (42 USC § 254e) or its implementing regulations, found in 42 CFR part 5. 

Whenever possible, respondents are asked to draw their responses from objective, empirical, and actionable evidence and to cite this evidence within their responses. HRSA may or may not choose to contact individual respondents. Such communications would only serve to clarify written responses.

HRSA welcomes feedback on the areas of consideration outlined below, as well as more general feedback or suggestions.

III. Feedback regarding current HPSA scoring criteria

HRSA welcomes feedback on current HPSA scoring criteria. As outlined below, this includes scoring criteria which are common to all three disciplines—primary care, dental health, and mental health, as well as discipline-specific criteria. This feedback may address current criteria and whether the current criteria are relevant in reflecting relative need, should continue to be used, should be altered, or whether point weights, values, or other scoring calculations should be changed. 

There are three main types of HPSAs – geographic, population and facility.

  • Geographic HPSAs mean there is a shortage of services for the entire population within an established geography.
  • Population HPSAs mean there is shortage of services for a specific population subset within an established geography. Some examples of populations frequently designated as population HPSAs include the Medicaid eligible, low income, migrant farmworker, American Indian/Alaskan Native, and homeless.
  • Facility HPSAs include two categories:
    • Facilities required to submit applications to determine designation eligibility (in accordance with the designation methodology established in federal regulation), including state and federal correctional facilities, state mental health hospitals, and public or non-profit clinics that serve the population of an existing geographic or population HPSA even if they are not located in it.
    • Facilities that HRSA automatically designates as HPSAs based on statute and regulations, referred to as Auto HPSAs. These include Federally Qualified Health Centers (FQHCs), FQHC Look-Alike, Medicare-certified Rural Health Clinics with implemented sliding fee policies, and Indian Health Service (IHS), tribal, and urban Indian health facilities.

1. Scoring criteria currently common to All HPSA Disciplines

  1. Population-to-Full-Time-Equivalent-Provider Ratio  A Population-to-Full-Time-Equivalent-Provider Ratio is used in HPSA scoring for all three disciplines.

    • 1a. Population: The population used for the Population-to-Provider ratio calculation for all disciplines is the total population of the service area that corresponds to the designation type (e.g., a geographic designation counts the total population of the service area, while a low income population designation counts the total population of the service area that is low income). 
    • 2a. Full-Time-Equivalent (FTE) Provider: The specific hours that the following provider types spend serving each population at a given location, including the general population, is used in the Population-to-Provider ratio calculation.
      • Primary Care: Physicians in General or Family Practice, General Internal Medicine, Pediatrics, or Obstetrics and Gynecology.
      • Dental Health: Dentist
      • Mental Health: Psychiatrist or Core Mental Health Providers (e.g., Clinical Psychologist, Clinical Social Worker, Psychiatric Nurse Specialist, or Marriage and Family Therapist)

        HRSA is seeking recommendations on whether this factor should be maintained. If so, HRSA seeks recommendations on the point scale to be applied.

  2. Percent of Population with Incomes below Poverty Level
    Poverty rate means the Federal Poverty Level defined by the Census Bureau, updated each year to reflect changes in the Consumer Price Index. 

    Poverty rates are widely acknowledged as a key measure of need for primary health services, and income levels correlate directly with access to health care and with health status measures.

    Currently, the poverty rate is double-weighted in only dental health.

    HRSA is seeking recommendations on whether this factor should be maintained. If so, HRSA seeks recommendations on the point scale to be applied.

  3. Travel Time or Distance to Nearest Source of Accessible Care outside the HPSA
    Nearest source of care is defined as the closest location where the residents of the designated area or population have access to comprehensive primary care services.

    HRSA is seeking recommendations on whether this factor should be maintained. If so, HRSA seeks recommendations on the point scale to be applied. 

2. Scoring criteria specific to Primary Care HPSAs

  1. Infant Health Index
    Infant mortality rate (IMR) or low birth weight (LBW) rate is one of the criteria used to compute the HPSA score for primary care designation.

    HRSA is seeking information on whether the standardized mortality ratio (SMR) for all populations should be included in lieu of IMR/LBW as a more inclusive indicator of need for primary care. If so, HRSA seeks recommendations on the point scale to be applied.

3. Scoring criteria specific to Dental Health HPSAs

  1. Fluoridated Water
    Presence of fluoridated water rate is one of the criteria used to compute the dental health HPSA score. A single point is awarded if an area’s rate is in the worst quartile for the nation, region, or state. 

    HRSA is seeking recommendations on whether this factor should be maintained. If so, HRSA seeks recommendations on the point scale to be applied.

4. Scoring criteria specific to Mental Health HPSAs

  1. Population-to-Full-Time-Equivalent-Provider Ratio 
    The FTE count of psychiatrists is required in all mental health HPSA applications, while the FTE count of other core mental health professionals is optional. Other core mental health professionals include: clinical psychologists, clinical social workers, marriage and family therapists, and psychiatric nurse specialists. Depending upon the data reported, the current HPSA scoring point scales utilize a population-to-psychiatrist ratio or a population-to-core mental health provider ratio. HRSA seeks input on whether these two scales should be maintained, or whether the FTE count of all core mental health professionals should be mandatory for scoring all mental health HPSAs.
  2. Youth Ratio
    The youth ratio is defined as the ratio of the number of children under age 18 to the number of adults of ages 18 to 64.

    HRSA is seeking recommendations on whether this factor should be maintained. If so, HRSA seeks recommendations on the point scale to be applied.

  3. Elderly Ratio
    The elderly ratio is defined as the ratio of the number of persons aged 65 and older to the number of adults of ages 18 to 64.

    HRSA is seeking recommendations on whether this factor should be maintained. If so, HRSA seeks recommendations on the point scale to be applied.

  4. Substance Use Disorder Prevalence
    A single point is awarded if an area’s rate is in the worst quartile for the nation, region, or state.

    HRSA is seeking recommendations on whether this factor should be maintained. If so, HRSA seeks recommendations on the point scale to be applied.

  5. Alcohol Use Disorder Prevalence
    A single point is awarded if an area’s rate is in the worst quartile for the nation, region, or state.

    HRSA is seeking recommendations on whether this factor should be maintained. If so, HRSA seeks recommendations on the point scale to be applied.

IV. Feedback regarding criteria not currently used in HPSA scoring, other factors, or alternative approaches

HRSA also welcomes feedback or proposals on alternative approaches to HPSA scoring. As outlined below, this includes proposals to include new criteria common to all three disciplines, as well as discipline-specific criteria. This feedback may address whether new criteria should be added, whether new criteria should replace existing criteria, whether new criteria reflects relative need, and/or whether point weights, values, or other HPSA scoring calculations should be changed. 

1. Incorporating Age Ranges

HRSA is seeking specific suggestions for how and to what extent we should consider incorporating age ranges in the determination of HPSA scoring. Such incorporation could include, but is not limited to:

  1. An elderly ratio, defined as the ratio of the number of persons aged 65 and older to the number of adults of ages 18 to 64;
  2. A youth ratio, defined as the ratio of the number of children under age 18 to the number of adults of ages 18 to 64; or
  3. An age-adjusted population metric.

2. Incorporating Rurality

HRSA is seeking specific suggestions for how and to what extent we should consider incorporating rurality in HPSA scoring, specifically using the Federal Office of Rural Health Policy (FORHP) definition of rurality which is based on Rural Urban Commuting Area (RUCA) codes. 

These suggestions could include recommendations on the point scale to be applied, incorporation of measures which may reflect overall health care burden in rural areas (e.g., age-adjusted metrics, additional incorporation of travel times to nearest sources of care, rates of specific illnesses or health outcomes, or statistically-significant prevalence of health-related behaviors), or other approaches.

3. Additional Feedback – Alternative Approaches

HRSA is seeking specific suggestions on how and to what extent the following should be considered in the determination of HPSA Scoring:

  1. Other factors. HRSA seeks recommendations on new criteria, which could be incorporated into HPSA scoring.
  2. Point scale. HRSA seeks recommendations on changes, which could be made to the current HPSA scoring scale.
  3. Any other approaches. HRSA seeks additional feedback not specifically mentioned by this RFI.   

V. Feedback regarding data sources used in HPSA scoring

HRSA seeks input as to which data sources to use in order to ensure accuracy and suitability of HPSA scoring methodology. While many sources of data are available for shortage designation in general, HRSA is open to using any additional data sources that will help fulfill the statutory mandate to distribute resources and providers to the areas of the greatest need.

Areas of Consideration for Public Input

  1. Relevance. Please provide input on the extent to which proposed data points and sources are relevant to assessing and/or describing the need in these areas.
  2. Universality. Please provide input on the extent to which proposed data points and sources are available for all 50 states, as well as U.S. territories.
  3. Accessibility. Please provide input on the extent to which proposed data points and sources are free and available to the public.
  4. Reliability. Please provide input on the extent to which proposed data points and sources are reviewable and published by reliable sources.
  5. Specificity. Please provide input on the extent to which proposed data points and sources are available down to the county, sub-county and/or census tract level.
  6. Current and up-to-date. Please provide input on the extent to which proposed data points and sources are current, and how frequently they are updated.

VI. Submitting Feedback

Respondents must provide responses to this RFI via email to RFIComments@hrsa.gov and you must reference “Health Professional Shortage Area Scoring Criteria RFI” in the subject line. Please include organization name, state, and partners (if applicable) in the body of the email. Your response should note the specific RFI question your comment addresses. If you provide comments to more than one question, please identify the specific RFI question each comment addresses. Information obtained as a result of this RFI may be used by the Government for program planning on a non-attribution basis. Respondents should not include any information that might be considered proprietary or confidential. HRSA is not obligated to respond to or directly address individual feedback. Comments will be received through 7:30 p.m. ET on 9/18/2020.

VII. Note to Commenters

This RFI is issued solely for information and planning purposes; it does not constitute a Request for Proposal, applications, proposal abstracts, or quotations. This RFI does not commit the Government to contract for any supplies or services or make a grant or cooperative agreement award or take any other official action. Further, HRSA is not seeking proposals through this RFI and will not accept unsolicited proposals.

HRSA is not obligated to summarize or publish a response to feedback received, or to respond to questions about the policy issues raised in this RFI. Responders are advised that the U.S. Government will not pay for any information or administrative costs incurred in response to this RFI; all costs associated with responding to this RFI will be solely at the interested party’s expense. Not responding to this RFI does not preclude participation in any future procurement or program, if conducted. It is the responsibility of the potential responders to monitor this RFI announcement for additional information pertaining to this request.

1Section 332 of the Public Health Service Act
242 CFR Part 5
3Criteria for Determining Priorities Among Health Professional Shortage Areas,” (PDF - 135 KB) 68 Fed. Reg. 32531 (May 30, 2003). 

Date Last Reviewed:  May 2020