Alternative methods for designating shortage areas are used within HRSA and other programs. Medically Underserved Areas (MUAs) is one such designation and was originally developed to assess a region’s primary care capacity and determine grantee eligibility for community health center grants. The HPSA and MUA designations depend on similar factors, but differ substantially in terms of the assessment procedure. While the shortage of health care providers is the primary factor in the designation of a HPSA, the MUA designation is based largely on the health needs of an area’s vulnerable population, measured in terms of the ratio of primary medical care physicians to 1,000 population, infant mortality rate, percentage of the population with incomes below poverty level, or percentage of the population age 65 or over (HRSA, 2013(g)).
States use a variety of shortage area designations for financial incentive programs that are similar to those of NHSC. In a study of 69 state-based programs operating in 40 states in 1996 (including loan repayment programs, scholarship programs, loan programs, direct incentive programs, and resident support programs), only 10 percent of programs used HPSA or MUA criteria without modification, while 35 percent of programs used these federal designations in conjunction with state-devised measures.16 More than half (55 percent) used unique criteria specific to their states sometimes specified within their state legislation (Pathman et al., 2004). More recent national estimates are currently not available. In the past, the Government Accountability Office (GAO) has criticized the methodology of both designations for their exclusion of certain types of physicians from provider counts, thus potentially inflating provider shortages (GAO, 1995). Additionally, neither the HPSA nor MUA designation calculation currently includes providers such as nurse practitioners, potentially overstating primary care provider shortages17. Some research also suggests that groups of sub-county service areas are often shaped for the purpose of securing a workforce shortage designation (Ricketts et al., 2007). Holmes (2005) further points out that because HPSA designation is self-initiated, communities with fewer resources may not apply.
16 In 1996, the 69 eligible programs were still relatively new and small, with median workforce size of 11 physicians (Pathman et al., 2004).
17 In 2011, the Negotiated Rulemaking Committee on the Designation of Medically Underserved Populations and Health Professional Shortage Areas proposed that nurse practitioners, physician assistants, and certified nurse midwives be included in the provider count for the development of the population-to-provider ratio (Health Resources and Services Administration, 2011(b)). To date, this proposal has not been acted upon.