05-2215. Development of Revised Need for Assistance Criteria for Assessing Community Need for Comprehensive Primary and Preventive Health Care Services Under the President's Health Centers Initiative

AGENCY:

Health Resources and Services Administration, HHS.

ACTION:

Solicitation of comments.

SUMMARY:

Currently, application scores for New Access Point (NAP) applications under the President's Health Centers Initiative (Program) cluster at the high end of the scoring range, providing little distinction among applicants. Since the intent of the Program is to provide grants to the neediest communities, HRSA is considering placing more emphasis on assessing the need for comprehensive primary and preventive health care services in the service area or for the population for which the applicant is seeking support, by revising the Need for Assistance Criteria and changing the relative weights of the review criteria used in evaluating such applications. This notice offers public and private nonprofit entities an opportunity to comment on the proposed changes in the Need for Assistance Criteria (NFA), and on the degree to which need should be weighted relative to other criteria used in evaluating future applications. In order to solicit comments from the public on these proposed changes, HRSA is delaying the due date (May 23, 2005) for the second round of fiscal year (FY) 2005 New Access Point applications.

Authorizing Legislation: Section 330(e)(1)(A) of the Public Health Service Act, as amended, authorizes support for the operation of public and nonprofit private health centers that provide health services to medically underserved populations.

Reference: For the current Need for Assistance (NFA) criteria and other application review criteria, including weights used most recently, see Program Information Notice (PIN) 2005-01, titled ARequirements of Fiscal Year 2005 Funding Opportunity for Health Center New Access Point Grant Applications,” are available on HRSA's Bureau of Primary Health Care (BPHC) Web site at http://bphc.hrsa.gov/​pinspals/​pins.htm. That PIN detailed the eligibility requirements, review criteria, and awarding factors for applicants seeking support for the operation of New Access Points in FY 2005.

Background: The goal of the President's Health Centers Initiative, which began in FY 2002, is to increase access to comprehensive primary and preventive health care services to 1,200 of the Nation's neediest communities through new and/or significantly expanded health center access points over five years. These health center access points are to provide comprehensive primary and preventive health care services in areas of high need that will improve the health status of the medically underserved populations to be served and decrease health disparities. Services at these new access points may be targeted toward an entire community or service area or toward a specific population group in the service area that has been identified as having unique and significant barriers to affordable and accessible health care services.

While it is extremely important that NAP grant awards be made to entities that will successfully implement a viable and compliant program for the delivery of comprehensive primary health services to the populations or communities they propose to serve, HRSA also needs to assure that all applicants seeking support for a NAP applicant can demonstrate the need for such services in the community (area or population group) to be served and be evaluated on that need. Under the current guidance, NFA criteria are used to quantify barriers to access and identify health disparities. The NFA process also establishes a threshold which applicants must meet in order for their applications to be reviewed by the Objective Review Committee (ORC).

Description of Current NFA process. The current NFA process (as described in Form 9-Part A of PIN 2005-01) involves two major groups of indicators. First, from eight (8) “Barriers and Access to Care” measures, the applicant must select five (5). These measures are: Shortage of primary care physicians, as measured by whether the target service area has been designated as a geographic or population group Health Professions Shortage Area (HPSA); Percent of the population with incomes below 200% of the Federal poverty level; Life expectancy of target population (in years); percentage of target population uninsured; unemployment rate of target population; average travel time or distance to nearest source of primary care for target population; percentage of target population age 5 or older who speak a language other than English at home; and length of waiting time for public housing and Section 8 certificates for target population. For the first of these measures, the applicant receives 14 points if HPSA-designated and zero otherwise; for each of the other measures, the NFA criteria define a 6-level scale from 0 to 14 points. The applicant provides data for its service area or target population for each of the 5 measures selected, and identifies the source of data used. Given 5 indicators and a maximum of 14 points for each, there are a possible 70 points for the “Barriers and Access to Care” indicators.

Second, from 28 “Health Disparity Factors”, the applicant selects 10 and provides data on each for its service areas or target populations. For each factor selected, the applicant can receive 3 points if the value for the target population exceeds the benchmark used. The applicant defines the benchmark, and gives a source for that benchmark as well as a source for the target population data provided. The guidance lists 27 specific factors, plus an “other” category allowing the applicant to select one additional locally-relevant factor not anticipated by the guidance. This approach produces a possible 30 points for the “Health Disparities Factors” section; combined with the possible 70 for “Barriers and Access to Care” section, allowing a possible 100 total points are possible. In current guidance, the threshold for having the application reviewed has been set at an NFA score of 70 out of the possible 100 total points.

Need for Assistance Worksheets and the Application Review Process

In accordance with the guidance, all applicants are required to complete an NFA Worksheet, identifying the NFA indicators they have selected from the options available and providing the data on these indicators for their proposed service area or target population. The Worksheet is reviewed by an Objective Review Committee (ORC), and only those applicants that achieve a score of 70 or higher out of the possible 100 points have the merits of their application evaluated by the ORC. To date, under the President's Initiative, HRSA has found that most applicants achieve the minimum of 70 NFA points required in the current process for consideration of their application. Furthermore, under the current application review process, only 10% of the total (100) possible points are allocated to the applicant's description of the need for additional primary care services in the community or target population to be served. Currently, application scores cluster at the high end of the scoring range, providing little discrimination among applications.

For these reasons, HRSA arranged for an external evaluation of the NFA criteria and the use of need factors in the overall application review process. (The evaluation was conducted by a team of HSR, Inc., and the University of North Carolina's Cecil G. Sheps Center for Health Services Research.) Key results of the evaluation analyses are presented below, followed by recommendations for proposed changes on which we are soliciting comments.

Current NFA Access Barriers—Frequency of Applicant Use; Scores Achieved

An analysis of applications received during FY 2004 indicated that, with respect to the eight “Barriers and Access to Care” indicators, 92% of applicants selected the indicator percent of target population below 200% poverty; 79% selected percent of target population uninsured; 78% selected shortage of primary care physicians; and 75% selected unemployment rate for the target population, while only 36% selected life expectancy of the target population and 34% selected travel time or distance. Language other than English and shortage of Public Housing were selected by 55% and 50% of the applicants respectively. Since applicants naturally chose the variables that gave them the highest scores, the average scores achieved on all of the “Barriers and Access to Care” indicators ranged from 12 to 14 for each, except for life expectancy, which had an average score of about 11. As a result, scores of 60 or more for the “Barriers and Access to Care” section were routinely obtained.

Current NFA Disparity Factors—Frequency of use by applicants. A similar analysis of the “Health Disparity Factors” selected by the same group of applicants showed that 8 indicators were selected by 50% or more of the applicants, and another 7 indicators were selected by one-third or more applicants. Twelve indicators were selected by 25% or fewer of the applicants. Ninety-five percent of the time a selected indicator received 3 points; only 5% of the time did an applicant receive 0 rather than 3 points for a disparity indicator supplied. Therefore, typically, at least 27 points were received for the “Health Disparities Factors” section. Combining at least 60 points for the “Barriers and Access to Care” section access barriers and 27 points for the “Health Disparities Factors” section, a typical application would get 87 points, easily exceeding the threshold of 70.

Distribution of All U.S. Counties on Current NFA Barrier Score Levels. To arrive at an understanding of why the scores for access barriers ran so high for most applications, an analysis of the scores that would be achieved by all 3,141 U.S. counties or county-equivalents was conducted. This analysis showed that, given the existing scales:

• On Percent Below 200% of Poverty, 665 of 3141 counties receive 14 points, another 993 receive 12 points, and 946 receive 10 points. The average county score is 11 points.
• On Life Expectancy, only 17 counties receive 14 points, but 601 counties receive 12 points, and 2,140 receive 10 points. The average county score is 10.1 points.
• On Unemployment Rate, the counties are distributed more evenly along the scoring scale, but only 2 counties receive zero points, and the average county score is 9.5 points.
• On Percent Uninsured, 1,609 counties receive 10 points, while 1,327 receive 8 points. The average county score is 9 points.
• By contrast, Travel Time/Distance shows better distinctions among counties using its existing scale; while 1,527 counties receive zero points, 950 receive 6 points, 294 receive 8 points, 112 receive 10 points, 52 receive 12 points and 51 receive 14 points. The average score is 3.5. HRSA is requesting feedback as to whether the scale should be adjusted to increase the numbers of counties getting 10, 12 or 14 points?
• In the case of Language other than English, the current scale seems to err in the direction of overly minimizing the points received: 2,410 counties receive zero points, and the average county score is only 1.8 points.
• On Shortage of Primary Care Physicians, 2,565 counties receive no points while 576 receive 14 points. This means that about one-sixth of counties are getting the maximum points, because they are wholly designated as HPSAs. This does not provide any flexibility in terms of the rest of the counties, some of which may be closer to eligibility for HPSA designation than others, while others contain part-county HPSAs.

Recommendations for Revising NFA Criteria/Worksheet. Based on the analysis described above, feedback from communities, applicants and several focus group sessions, HRSA is proposing the following changes to the NFA criteria and process:

• Require that three (3) major access barriers be measured for all applicants. These three would be (a) percent of the population with incomes below 200 percent of the poverty level, (b) percent of population uninsured, and (c) shortage of primary care physicians, the three barriers that are most frequently selected by applicants.
• Use the population-to-primary care physician ratio for the applicant's service area or target population as the measure of shortage of primary care physicians, rather than a simple yes/no response based on presence or absence of a HPSA designation, with a scale of the type used for the other access indicators.
• Allow the applicant to select two additional access barriers from the following five (5): Unemployment Rate of Population, Percent Linguistically Isolated Population (replacing language other than English), Standardized Mortality Rate for Population (replacing Life Expectancy Rate), Travel Time/Distance to Nearest Provider accepting Medicaid and/or Uninsured Patients, and (for Homeless or Public Housing applicants only) Waiting time for Public Housing.
• Choose the scale for each of the access indicators based on comparison to the national county distribution of that indicator. (The scales proposed to be used are displayed below.) No points would be awarded for a barrier value better than the national county median.
• Require that 5 “core” disparity factors closely related to health center primary care activities be measured for all applicants. The core indicators proposed are: asthma rate, diabetes rate, and cardiovascular disease rate among the population; one birth outcome measure (infant mortality rate or low live birthweight rate), and one mental health measure (depression rate or suicide rate) among population. [Of these factors, all but one (depression rate) were in the group of current indicators selected at least 33% of the time.]
• Allow 2 points for each core disparity factor on which the community value exceeds the national benchmark for that factor, which would be provided in HRSA's application guidance (rather than by the applicant). Allow an additional point if a higher “severe” benchmark, also specified in the guidance, is also exceeded. (Benchmarks proposed are appended below.)
• Have the applicant select 5 additional disparity factors from a list of 7 factors previously used that are closely related to health center primary care activities. The factors proposed are: immunization rate, hypertension rate, rate of respiratory infection, obesity, teenage pregnancy, substance abuse, and percent elderly population. Alternatively, the applicant may select 4 of these plus an “other” indicator specified by the applicant.
• Allow 2 points for each selected measure on which the community value exceeds the national benchmark. (Benchmarks proposed are appended below.) If “other” is selected, the applicant would need to both define the measure and suggest a benchmark for it as well. If the measure and the benchmark are accepted (or if the measure is accepted but the benchmark is redefined), 2 points would be allowed if the benchmark is exceeded.
• Maximum possible total points for access barriers here is 75; and for disparities is 25 points, totaling 100 possible total points for NFA.
• A threshold of 50 points on this revised index is under consideration. Only those applicants with a NFA score of 50 or more would have their application reviewed by the ORC. HRSA is considering whether this threshold should be changed annually to maintain a certain ratio of number of applications reviewed to number of awards available.
• The NFA scores achieved could be factored into the application review process.

Relative Importance of Need as an Application Review Factor

The evaluation team also recommended that the relative need score from the NFA worksheet should be the basis for 20 percent of total application score, replacing the previous 10% for “description of service area/community and target population.” To accommodate this change, the evaluation team suggested reducing the proportion of the total application score now assigned to “Governance” from 10% to 5%, and reducing the proportion of total score assigned to “Service Delivery Strategy and Model” from 20% to 15%. However, HRSA has not taken a position on what new relative weighting might be most appropriate. Instead, by this notice, we are requesting public comments on this issue. Specifically, how should Need considerations be weighted in the application review process? What is the relative importance of Need versus such other factors as applicant Readiness to operate a health center, understanding of and connections to the local health care Environment, service delivery Strategy for addressing the needs of the community, plan for provision of specific required health Services, Organizational capabilities and expertise, Budget plan, and Governance? Rather than providing specific suggested percentages for weighting all these different factors, commenters are encouraged to isolate how Need should be weighted relative to all other factors, and whether this should be done by applying that weight to an objective index of relative community need such as that proposed above, or in some other manner.

DATES:

Please send comments no later than COB March 7, 2005. The comments should be addressed to Dr. Sam Shekar, Associate Administrator for Primary Health Care, Health Resources and Services Administration, Room 17-99, 5600 Fishers Lane, Rockville, Maryland 20857.

FOR FURTHER INFORMATION CONTACT:

Ms. Lynn Spector, Division of Health Center Development, Bureau of Primary Health Care, HRSA. Ms. Spector may be contacted by e-mail at [e-mail] or via telephone at [phone].

Dated: February 1, 2005.

Elizabeth M. Duke,

Administrator.