Provider Retention in High Need Areas. Definitions and Measures


Definition of HPSAs


The Health Professional Shortage Areas (HPSA) designation and scores are managed by the Health Resources and Services Administration’s (HRSA) Office of Shortage Designation. They identify geographic areas, facilities, and population groups within the United States that are experiencing a shortage of primary medical care, dental, or mental health providers. HPSA designations are determined based on the entities’ application to the Bureau of Health Workforce.

Within each discipline (primary care, dental, or mental health), there are three types of designations (Health Resources and Services Administration, 2013(c); HRSA, 2013 (d); HRSA, 2013(e)):

  • Geographic designations, which depend on the ratio between full-time equivalent (FTE) clinical providers and the patient population within a given area;

  • Population designations, that depend on the ratio between FTE clinical providers who serve a particular underserved population group and the size of the underserved population; and

  • Facility designations, which are based on criteria relating to one of three types of facilities, including federal and state correctional institutions and youth detention facilities, public or nonprofit private facilities, and state and county mental hospitals. Facilities must be serving patients from a previously designated population or geographic area and must prove that available capacity is insufficient to meet the level of need.

Geographic and population designations are based on characteristics of health care delivery within specific geographic areas or population groups. A service area can be a single county, group of counties, a partial-county, or a group of partial-counties. Partial-county geographic designations must comprise neighborhood or community areas whose characteristics are sufficiently different from surrounding areas (e.g., low income, high concentration of homeless, existence of isolating physical barriers, and extremely rural or remote areas).

Regions that are contiguous to geographic or population HPSAs must not contain adequate primary care resources that are readily accessible by the population residing within the HPSA. Resources in these nearby areas must be prohibitively distant or over-utilized.

NHSC-approved HPSA service sites include (National Health Services Corps, 2013):

  1. Federally Qualified Health Centers (FQHC);

  2. FQHC Look-Alikes;

  3. Rural Health Clinics (RHC);

  4. Hospital-affiliated Primary Care Outpatient Clinics;

  5. Indian Health Service, Tribal Clinic, and Urban Indian Health Clinics;

  6. State or Federal Correctional Facilities;

  7. Private Practices (Solo/Group); and

  8. Other Health Facilities, including:

    • Community Mental Health Facilities;

    • Community Outpatient Facilities;

    • Critical Access Hospitals (CAHs);

    • Free Clinics;

    • Immigration and Customs Enforcement (ICE) Health Services Corps;

    • Mobile Units;

    • School-based Health Programs; and

    • State and County Department Health Clinics.

These sites provide comprehensive outpatient, ambulatory, and primary health care services, while inpatient services may be provided by NHSC-associated CAHs. FQHCs, FQHC Look-Alikes, and Indian Health Service sites are automatically approved as NHSC sites so long as they meet all NHSC site requirements and the requirements of their respective facility type.

NHSC-approved sites of all types are rated on the degree of shortage, which is used in part to determine priorities for the placement of NHSC clinicians. Scores range from 1 to 25 for primary care and mental health facilities, and from 1 to 26 for dental care facilities, with 1 indicative of “lowest priority”. Automatic facility designations may receive a HPSA designation of 0 (HRSA Shortage Designation, 2013). Variables determining a HPSA score include the service area’s percent of population below poverty, an Infant Health index, and travel distance to the nearest accessible care outside of the HPSA. . HPSA scoring for all primary care facilities depends on four factors: population-to-primary care physician ratio, percent of the population with incomes below 100 percent of poverty level, infant mortality rate or low birth weight rate (whichever score is higher), and travel time or distance to nearest available source of care (whichever score is higher).

Currently, HPSA designations are used to define workforce shortages in primary care,, dental, and mental health HPSAs. Workforce shortage designations were developed in the mid-1960s (Salinsky, 2010), concurrent with the implementation of loan repayment programs and scholarship programs that were predecessors of modern NHSC programs. In the past, a similar designation was also used to characterize shortages in other health professions, including pharmacy, podiatry, and veterinary medicine (Salinsky, 2010).

In the past few years, several updates to the HPSA definition and NHSC recruitment policies have had effects on recruitment and retention. We review below three of these most important updates.

  1. The Health Care Safety Net Amendment of 2002 included a provision for the automatic designation of certain types of facilities as HPSAs. All FQHCs, FQHC-Look-Alikes, IHS sites, and certain Rural Health Clinics that provide care regardless of the patients’ ability to pay are automatically designated as HPSAs on the date when they are approved as one of these provider types. HPSA designation is required to be updated on a regular basis, but auto HPSA scores are only updated upon request.

  2. In 2009, as a result of the surge in funding from ARRA, NHSC cancelled the HPSA score floor requirement. The NHSC proceeded to allow clinics in all HPSAs to apply to become NHSC sites. This, in turn, nearly doubled the number of service sites, creating thousands of additional openings for NHSC clinicians (Pathman et al., 2012(a)).

  3. NHSC identified priority HPSAs to ensure adequate assignment to areas with the highest levels of need. As of January 2014, the NHSC LRP offers two levels of funding based on HPSA score. Initial award amounts for clinicians who serve at sites with HPSA scores of 0-13 may receive up to $30,000 for a two-year full-time commitment, or up to $15,000 for a two-year half-time commitment. Those who serve at sites with HPSA score of 14 or more may receive up to $50,000 or up to $25,000 for a two-year, full-time or half-time commitment, respectively (NHSC, 2014). NHSC Scholars are required to serve in HPSAs of greatest need, a classification that is determined each year. From July 1, 2013 through June 30, 2014, NHSC SP recipients must serve at NHSC-approved sites with a HPSA score of 16 or above for their discipline (NHSC, 2014).

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