during portion of year that tourists are present).

(ii) The migrant population will be included in an area's population, as computed according to the following formula: Effective migrant population (proportion of year migrants are present in area) x (average daily number of migrants during portion of year that migrants are present).

=

3. Counting of Primary Care Practitioners. (a) All non-Federal doctors of medicine (M.D.) and doctors of osteopathy (D.O.) providing direct patient care who practice principally in one of the four primary care specialties-general or family practice, general internal medicine, general pediatrics, and obstetrics and gynecology-will be counted. Those physicians engaged solely in administration, research, and teaching will be excluded. Hospital-based primary care physicians will be included to the extent that they provide ambulatory services and first-contact care. Adjustments for the following factors will be made in counting physicians, however:

(1) Interns and residents will be counted as .5 full-time equivalent (FTE) physicians to reflect the fact that a large portion of their time is spent in training.

(ii) Foreign medical graduates (i.e., graduates of medical programs outside the U.S.) who do not have a stable immigration status (i.e., U.S. citizenship or a permanent visa) will be excluded from physician counts since their future availability to help provide medical care to the area's population is uncertain.

(iii) Foreign medical graduates who have a stable immigration status, but are not fully licensed to practice medicine will be counted as 0.5 FTE physicians to reflect their practice limitations and time spent in training.

(b) Practitioners who are semi-retired, who operate a reduced practice due to infirmity or other limiting conditions, or who are available to the population of an area only on a part-time basis will be discounted through the use of full-time equivalency figures. A 40-hour work week will be used as the standard for determining full-time equivalents in such cases. For practitioners working less than a 40-hour week, every four (4) hours (or 1/2 day) spent providing patient care, in either ambulatory or inpatient settings, will be counted as 0.1 FTE (with numbers obtained for FTEs rounded to the nearest 0.1 FTE), and each physician providing patient care 40 or more hours a week will be counted as 1.0 FTE physician.

(c) In some cases, physicians located within an area may not be accessible to the population of the area under consideration. Allowances for physicians with restricted practices will be made, on a case-by-case basis. Examples of such restricted practices

include refusal to accept certain types of patients or to accept Medicaid reimbursement.

(d) Nurse practitioners and physician's assistants also make important contributions to the provision of primary medical care services. While national equivalency figures for taking the availability of nurse practitioners and physician's assistants into account are not included here because of variations in their responsibilities across States and regions, their contribution to the supply of primary care services in individual areas will be considered where appropriate data are available.

4. Determination of Unusually High Needs for Primary Medical Care Services. An area will be considered as having unusually high needs for primary medical care services if at least one of the following criteria is met:

(a) The area has more than 100 births per 1,000 women aged 15-44, or more than 40 births per 1,000 women aged 13-17.

(b) The area has more than 20 infant deaths per 1,000 live births.

(c) More than 30 percent of the population (or of all households) have incomes below the poverty level.

5. Determination of Insufficient Capacity of Existing Primary Care Providers. An area's existing primary care providers will be considered to have insufficient capacity if at least two of the following criteria are met:

(a) More than 8,000 office or outpatient visits per year per FTE primary care physician serving the area.

(b) Unusually long waits for appointments for routine medical services (i.2., more than 7 days for established patients and 14 days for new patients).

(c) Excessive average waiting time at primary care providers (longer than one hour where patients have appointments or two hours where patients are treated on a firstcome, first-served basis).

(d) Evidence of excessive use of emergency room facilities for routine primary care.

(e) A substantial proportion ( 2/3 or more) of the area's physicians do not accept new patients.

(f) Abnormally low utilization of health services, as indicated by an average of 2.0 or less office visits per year on the part of the area's population.

6. Contiguous Area Considerations. Primary care manpower in areas contiguous to an area being considered for designation will be considered excessively distant, overutilized or inaccessible to the population of the area under consideration if one of the following conditions prevails in each contiguous area:

(a) Primary care manpower in the contig. uous area are more than 30 minutes travel time from the center of the area being considered for designation (measured in accordance with paragraph B.1(b) of this Part).

(b) Contiguous area population-to-FTE primary care physician ratios are in excess of 2,500:1, indicating that contiguous areas cannot be expected to help alleviate the shortage situation in the area being considered for designation.

(c) Primary care manpower in contiguous areas are inaccessible to the population of the area under consideration because of specified access barriers, such as:

(1) Significant differences between the demographic (or socio-economic) characteristics of the area under consideration and those of the contiguous area, indicating that the population of the area under consideration may be effectively isolated from nearby resources. Such isolation could be indicated, for example, by an unusually high proportion of non-English-speaking persons.

(ii) The area's population lacks economic accessibility to contiguous area resources. For those areas where a very high proportion of the population is poor (i.e., where more than 30 percent of the population or of the households have incomes below the poverty level), failure of a substantial majority of contiguous area providers to accept Medicaid will be taken to indicate such economic inaccessibility. Contiguous where the ratio of poverty population to number of primary care physicians accepting Medicaid is higher than 2,500:1 will then be assumed to have no excess capacity which can relieve the shortage in the area under consideration.

areas

group 2 areas will be assumed to have a greater shortage than all group 3 areas, etc.

2. Relative Shortage within a Group. In comparing any two areas within each group as defined above, the area with the larger population will be assumed to have the greater shortage.

PART II-POPULATION GROUPS

A. Criteria.

The following population groups will be designated as having a shortage of primary medical care manpower:

(1) Those American Indians and Alaska Natives who are members of Indian tribes (as defined in section 4(d) of Pub. L. 94-437, the Indian Health Care Improvement Act of 1976);

(2) Other American Indians (as defined in section 4(c) of Pub. L. 94-437), migrant populations, and other population groups within particular geographic areas will be designated if the following criteria are met: (a) Access barriers prevent the population group from use of the area's primary medical providers (such as refusal of practitioners to accept certain types of patients or refusal to accept Medicaid reimbursement); and

(b) The ratio (R) of the number of persons in the population group to the number of FTE primary care physicians serving the population group, and practicing within 30 minutes travel time of the center of the area where the population group resides, is at least 3,500:1 (3,000:1, where unusually high needs for health services exist in the population group, as determined in accordance with paragraph B.4 of Part I of this Appendix). The population of the group is to be counted in accordance with paragraph B.2 of Part I of this Appendix, except that for migrant populations in high impact areas (as defined in section 319(a)(5) of the Act), the average number of migrants in the area during the period of highest impact will be used.

B. Determination of Degree of Shortage The degree of shortage of a given population group, designated as having a shortage of primary care manpower, will be determined as follows:

1. The population group will first be assigned to a degree-of-shortage grouping as in Paragraph C of Part I of this Appendix, based on the ratio (R) of the group's population to the number of primary care physicians serving it, together with the presence or absence of unusually high needs for primary medical care services among the population group.

2. In comparing any two population groups within a degree-of-shortage grouping, or in comparing a designated popula

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tion group with a designated area within the same grouping, the area or population group with the larger population will be assumed to have the greater shortage. (In the case of Indian tribes, the population figure used will be that population served by each Indian Health Service (IHS) facility which requires staffing.)

PART III-FACILITIES

A. Federal and State Correctional
Institutions

1. Criteria. Medium to maximum security Federal and State correctional institutions will be designated as having a shortage of primary medical care inanpower if both the following criteria are met:

(a) The institution has at least 250 inmates.

(b) The ratio of the number of internees per year to the number of FTE primary care physicians serving the institution is at least 1,000:1. (The number of internees is the number of inmates present at the beginning of the year plus the number of new inmates entering the institution during the year, including those on short sentences who left before the end of the year.)

2. Determination of Degree of Shortage. The degree of shortage of a given correctional institution, designated as having a shortage of primary care medical manpower, will be determined as follows:

(a) Grouping of correctional institutions. Correctional institutions will first be grouped as follows, based on number of inmates and/or the ratio (R) of internees to primary care physicians:

Group 1-Institutions with 500 or more inmates and no physicians.

Group 2-Institutions with 250-499 inmates and no physicians; or with any number of inmates and R<2,000.

Group 3-Institutions with 2,000 R<1,000. (b) Relative shortage within a group. In comparing any two institutions within a given group, the institution with the larger number of internees will be assumed to have the greater shortage.

B. Public or Non-profit Private Medical
Facilities

1. Criteria. Public or nonprofit private medical facilities will be designed as having a shortage of primary medical care manpower if:

(a) The facility is providing primary medical care services to an area or population group designated as having a primary care manpower shortage; and

(b) The facility has insufficient capacity to meet the primary care needs of that area or population group.

2. Methodology. In determining whether public or nonprofit private medical facilities

meet the criteria established by paragraph B.1 of this Part, the following methodology will be used:

(a) Provision of Services to a Designated Area or Population Group. A facility will be considered to be providing services to a designated area or population group if either:

(i) A majority of the facility's primary care services are being provided to residents of designated primary care manpower shortage areas or to population groups designated as having a shortage of primary care manpower; or

(ii) The population within a designated primary care shortage area or population group has reasonable access to primary care services provided at the facility. Such reasonable access will be assumed if the population lies within 30 minutes travel time of the facility and non-physical barriers (relating to demographic and socioeconomic characteristics of the population) do not prevent the population from receiving care at the facility.

Indian Health Service facilities and migrant health centers (as defined in section 319(a)(1) of the Act) are assumed to be meeting this requirement.

(b) Insufficient capacity to meet primary care needs. A facility will be considered to have insufficient capacity to meet the primary care needs of a designated area or population group if at least two of the following conditions exist at the facility:

(i) There are more than 8,000 outpatient visits per year per primary care physician on the staff of the facility.

(ii) There is excessive usage of emergency room facilities for routine primary care.

(iii) Waiting time for appointments is more than 7 days for established patients and/or more than 14 days for new patients seeking routine health services.

(iv) Waiting time at the facility is longer than one hour where patients have appointments or two hours where patients are treated on a first-come, first-served basis.

Indian Health Service facilities will be considered to have insufficient capacity if the staffing requirements established by the Indian Health Service are not met.

3. Determination of Degree of Shortage. The degree of shortage of a medical facility designated as having a shortage of primary medical care personnel will be determined as follows:

(a) Grouping of areas. Medical facilities will be grouped as in Paragraph C of Part 1 of this Appendix, in the same groupings as the designated area or population group which they serve.

(b) Relative shortage within a group. In comparing a facility with other designated facilities, areas, or population groups within the same grouping, the population figure used for the facility shall be that of the

population of the designated area or population group which the facility serves. The area, population group, or facility with the larger population or service population will then be assumed to have the greater shortage.

APPENDIX B-CRITERIA FOR DESIGNATION OF AREAS HAVING SHORTAGES OF DENTAL MANPOWER

PART I-GEOGRAPHIC AREAS

A. Criteria

A geographic area will be designated as having a dental manpower shortage if the following three criteria are met:

1. The area is a rational area for the delivery of dental services.

2. One of the following conditions prevails in the area:

(a) The area has a population-to-dentist ratio of at least 5,000:1, or

(b) The area has a population-to-dentist ratio of less than 5,000:1 but greater than 4,000:1 and has either unusually high needs for dental services or insufficient capacity of existing dental providers.

3. Dental manpower in contiguous areas are overutilized, excessively distant, or inaccessible to the population of the area under consideration.

B. Methodology

In determining whether an area meets the criteria established by paragraph A of this Part, the following methodology will be used:

1. Rational Areas for the Delivery of Dental Services. (a) The following areas will be considered rational areas for the delivery of dental services:

(i) A county, or a group of several contiguous counties whose population centers are within 40 minutes travel time of each other.

(ii) A portion of a county (or an area made up of portions of more than one county) whose population, because of topography, market or transportation patterns, distinctive population characteristics, or other factors, has limited access to contiguous area resources, as measured generally by a travel time of greater than 40 minutes to such re

sources.

(iii) Established neighborhoods and communities within urbanized areas which display a strong self-identity (as indicated by a homogenous socioeconomic or demographic structure and/or a tradition or interaction or intradependency), have limited interaction with contiguous areas, and which, in general, have a minimum population of 20,000.

(b) The following distances will be used to estimate distances corresponding to 40 min

utes travel time: (i) Under normal conditions with primary roads available: 30 miles. (ii) In mountainous terrain or in areas with only secondary roads available: 20 miles.

(iii) In flat terrain or in areas connected by interstate highways: 35 miles.

Within inner portions of metropolitan areas, the large variations in the scope of public transportation systems and traffic conditions do not permit standard mileage figures to be specified. In these areas, information on the public transportation system will be used to determine the distance corresponding to 40 minutes travel time.

2. Population Count. The population count used will be the total permanent resident civilian population of the area, excluding inmates of institutions, with the following additions to take into account the effect of transient populations, where appropriate: (a) Seasonal tourist populations will be included in an area's population with a weight of 0.5, as computed according to the following formula: Effective tourist population=.5×(proportion of year tourists are present in area)x(average daily number of tourists during portion of year that tourists are present).

(b) The migrant population will be included in an area's population, as computed according to the following formula: Effective migrant population=(proportion of year migrants are present in area)×(average daily number of migrants during portion of year that migrants are present).

3. Counting of Dental Practitioners. (a) All non-Federal dentists providing patient care will be counted, except in those urban areas where it is shown that specialists (those dentists not in general practice or pedodontics) are serving a larger metropolitan area and are not addressing the general dental care needs of the area under consideration.

(b) Full-time equivalent (FTE) figures will be used to reflect productivity differences among dental practices based on the age of the dentists, the number of auxiliaries employed, and the number of hours worked per week. In general, the number of FTE dentists will be computed using weights obtained from the matrix in Table 1, which is based on the productivity of dentists at various ages, with different numbers of auxiliaries, as compared with the average productivity of all dentists. For the purposes of these determinations, an auxiliary is defined as anH non-dentist staff employed by the dentist to assist in operation of the practice.

The number of equivalent dentists within a particular age group (or age/auxiliary group) will be obtained by multiplying the number of dentists within that group by its corresponding equivalency weight. The total supply of equivalent dentists within an area is then computed as the sum of those dentists within each age (or age/auxiliary) group.

(c) The equivalency weights specified in Tables 1 and 2 assume that dentists within a particular group are working full-time (40 hours per week). Where appropriate data are available, adjusted equivalency figures for dentists who are semi-retired, who operate a reduced practice due to infirmity or other limiting conditions or who are available to the population of an area only on a part-time basis will be used to reflect the reduced availability of such dentists. In computing such equivalency figures, every 4 hours (or 1/2 day) spent in the dental practice will be counted as 0.1 FTE, except that each dentist working more than 40 hours a week will be counted as 1.0. The count obtained for a particular age group of dentists will then be multiplied by the appropriate equivalency weight from Table 1 or 2 to obtain a full-time equivalent figure for dentists within that particular age or age/auxiliary category.

4. Determination of Unusually High Needs for Dental Services. An area will be considered as having unusually high needs for dental services if at least one of the following criteria is met:

(a) More than 30 percent of the population (or of all households) have incomes below the poverty level.

(b) The area does not have a fluoridated water supply.

5. Determination of Insufficient Capacity of Existing Dental Care Providers. An area's existing dental care providers will be considered to have insufficient capacity if any of the following criteria are met:

(a) More than 5,000 visits per year per FTE dentist serving the area.

(b) Unusually long waits for appointments for routine dental services (i.e., more than 6 weeks).

(c) A substantial proportion ( 2/3 or more) of the area's dentists do not accept new patients.

6. Contiguous Area Considerations. Dental manpower in areas contiguous to an area being considered for designation will be considered excessively distant, overutilized or inaccessible to the population of the area under consideration if one of the following conditions prevails in each contiguous area:

(a) Dental manpower in the contiguous area are more than 40 minutes travel time from the center of the area being considered for designation (measured in accordance with paragraph B.1.(b) of this Part).

(b) Contiguous area population-to-FTE dentist ratios are in excess of 3,000:1, indicating that resources in contiguous areas cannot be expected to help alleviate the shortage situation in the area being considered for designation.

(c) Dental manpower in contiguous areas are inaccessible to the population of the area under consideration because of specified access barriers, such as:

(i) Significant differences between the demographic (or socioeconomic) characteristics of the area under consideration and those of the contiguous area, indicating that the population of the area under consideration may be effectively isolated from nearby resources. Such isolation could be indicated, for example, by an unusually high proportion of non-English-speaking persons.

(ii) The area's population lacks economic accessibility to contiguous area resources, particularly those areas where a very high proportion of the population is poor (i.e., where more than 30 percent of the population or of the households have incomes below the poverty level).

C. Determination of Degree of Shortage

The degree of shortage of a given geographic area, designated as having a shortage of dental manpower, will be determined using the following procedure:

1. Grouping of Areas. Designated areas will first be assigned to groups, based on the ratio (R) of population to number of fulltime equivalent dentists and the presence or absence of unusually high needs for dental services or insufficient capacity of existing dental care providers, according to the following table: