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standard metropolitan statistical area (SMSA). All other areas are “non-metropolitan areas."

Poverty level means the povery level as defined by the Bureau of the Census, using the poverty index adopted by a Federal Interagency Committee in 1969, and updated each year to reflect changes in the Consumer Price Index.

Secretary means the Secretary of Health and Human Services and any other officer or employee of the Department to whom the authority involved has been delegated.

State includes, in addition to the several States, the District of Columbia, the Commonwealth of Puerto Rico, the Northern Mariana Islands, the Virgin Islands, Guam, American Samoa, and the Trust Territory of the Pacific Islands.

State health planning and development agency or SHPDA means a State health planning and development agency designated under section 1521 of the Act.

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(b) In addition, any agency or vidual may request the Secretary designate (or withdraw the designas of) a particular geographic area, De lation group, or facility as a les professional(s) shortage area. Esci quest will be forwarded by the $ retary to the appropriate E SHPDA, and Governor, who will asked to review it and offer their ommendations, if any, within 30 da" An information copy will also be me available to other interested parts upon request, for their use in prović comments or recommendations to : Secretary and/or to the appropris HSA, SHPDA, or Governor.

(c) In each case where the desio tion of a public facility (including Federal medical facility) is under o sideration, the Secretary will g? written notice of the proposed desig tion to the chief administrative office of the facility, who will be asked to view it and offer their recommen tions, if any, within 30 days.

(d) After review of the available in formation and consideration of it comments and recommendations sol mitted, the Secretary will designa health professional(s) shortage area and withdraw the designation of an areas which have been determined 1: longer to have a shortage of heale professional(s). 85.4 Notification and publication or

designations and withdrawals. (a) The Secretary will give writte: notice of the designation (or with drawal of designation) of a professional(s) shortage area, not late: than 60 days from the date of the des ignation (or withdrawal of designation), to:

(1) The Governor of each State ir which the area, population group, medical facility, or other public facility 80 designated is in whole or in part 10cated;

(2) Each HSA for a health service area which includes all or any part of the area, population group, medical facility, or other public facility so designated;

(3) The SHPDA for each State in which the area, population group, medical facility, or other public facility 80

(a) Using data available to the Department from national, State, and local sources and based upon the criteria in the appendices to this part, the Department will annually prepare listings (by State and health service area) of currently designated health professional(s) shortage areas and potentially designatable areas, together with appropriate related data available to the Department. Relevant portions of this material will then be forwarded to each health systems agency, State health planning and development agency, and Governor, who will be asked to review the listings for their State, correct any errors of which they are aware, and offer their recommendations, if any, within 90 days, as to which geographic areas, population groups, and facilities in areas under their jurisdiction should be designated. An information copy of these listings will also be made available, upon request, to interested parties for their use in providing comments or recommendations to the Secretary and/or to the appropriate HSA, SHPDA, or Governor.

health

iignated is in whole or in part lo- (ii) If the average length-of-stay is specied; and

fied as one year or more, and intake medical 34) Appropriate public or nonprofit

examinations are routinely performed upon

entry, then-Number of internees-average svate entities which are located in or

number of inmates+(0.3)~number of new inich have a demonstrated interest in

mates per year. We area so designated.

(111) If the average length-of-stay is specib) The Secretary will periodically fied as less than one year, and intake examiblish updated lists of designated

nations are routinely performed upon entry, ealth professional(s) shortage areas in

then-Number of internees=average number

of inmates+(0.2)x(1+ALOS/2)xnumber of new e FEDERAL REGISTER, by type of

inmates per year where ALOS-average ofessional(s) shortage. An updated

length-of-stay (in fraction of year). (The 33t of areas for each type of

number of FTE primary care physicians 18 sofessional(s) shortage will be pub- computed as in part I, section B, paragraph shed at least once annually.

3 above.) (C) The effective date of the designa

2. Determination of Degree of Shortage.

Designated correctional institutions will non of an area shall be the date of the

be assigned to degree-of-shortage groups zotification letter to the individual or

based on the number of inmates and/or the gency which requested the designa- ratio (R) of internees to primary care physion, or the date of publication in the cians, as follows: EDERAL REGISTER, whichever comes Group 1-Institutions with 500 or more in.rst.

mates and no physicians. (d) Once an area is listed in the FED

Group 2Other institutions with no physi

cians and institutions with R greater than RAL REGISTER as a designated health

(or equal to) 2,000:1. Jrofessional(s) shortage area, the effec

Group 3-Institutions with R greater than Cive date of any later withdrawal of the

(or equal to) 1,000:1 but less than 2,000:1. irea's designation shall be the date B. Methodology. when notification of the withdrawal, or In determining whether an area meets the in updated list of designated areas

criteria established by paragraph A of this which does not include it, is published

part, the following methodology will be used:

1. Rational Areas for the Delivery of Primary in the FEDERAL REGISTER.

Medical Care Services.

(a) The following areas will be considered APPENDIX A TO PART 5-CRITERIA FOR

rational areas for the delivery of primary
DESIGNATION OF AREAS HAVING medical care services:
SHORTAGES OF PRIMARY MEDICAL (1) A county, or a group of contiguous
CARE PROFESSIONAL(S)

counties whose population centers are within

30 minutes travel time of each other. Part IGeographic Areas

(ii) A portion of a county, or an area made A. Federal and State Correctional Institu

up of portions of more than one county,

whose population, because of topography, tions.

market or transportation patterns, distinc1. Criteria.

tive population characteristics or other facMedium to maximum security Federal and

tors, has limited access to contiguous area State correctional institutions and youth de

resources, as measured generally by a travel tention facilities will be designated as hav

time greater than 30 minutes to such reing a shortage of primary medical care

sources. - professional(8) if both the following criteria

(iii) Established neighborhoods and comare met:

munities within metropolitan areas which (a) The institution has at least 250 in

display a strong self-identity (as indicated 31 mates.

by a homogeneous socioeconomic or demo(b) The ratio of the number of internees

graphic structure and/or a tradition of inter$ per year to the number of FTE primary care

action or interdependency), have limited physicians serving the institution is at least interaction with contiguous areas, and 1,000:1.

which, in general, have a minimum popuHere the number of internees is defined as lation of 20,000. follows:

(b) The following distances will be used as (1) If the number of new inmates per year guidelines in determining distances corand the average length-of-stay are not speci- respond to 30 minutes travel time: fied, or if the information provided does not normal conditions with primary indicate that intake medical examinations roads : 20 miles. are routinely performed upon entry, then- (11) Inntalnog terrain or in areas Number of internees=average number of in- with only ondary rodillable: 15 mates.

miles.

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(iii) In flat terrain or in areas connected by interstate highways: 25 miles.

Within inner portions of metropolitan areas, information on the public transportation system will be used to determine the distance corresponding to 30 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 adjustments, where ap propriate:

(a) Adjustments to the populations differing health service requirement a ious age-sex population groups will be puted using the table below of visit az 12 age-sex population cohorts. The toz pected visit rate will first be obtaide. multiplying each of the 12 visit rates table by the size of the area populaticer in that particular age-sex cohort and sin the resultant 12 visit figures together. : total expected visit rate will then be ¿E by the U.S. average per capita visit naz 5.1, to obtain the adjusted population for

area.

Age groups

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care

(b) The effect of transient populations on the need of an area for primary professional(s) will be taken into account as follows:

(1) Seasonal residents, i.e., those who maintain a residence in the area but inhabit it for only 2 to 8 months per year, may be included but must be weighted in proportion to the fraction of the year they are present in the area.

(11) Other tourists (non-resident) may be included in an area's population but only with a weight of 0.25, using the following formula: Effective tourist contribution to population=0.25x(fraction of year tourists are present in area)x(average daily number of tourists during portion of year that tourists are present).

(iii) Migratory workers and their families may be included in an area's population, using the following formula: Effective migrant contribution to population=(fraction 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 specialities-general or family practice, general internal medicine, pediatrics, and obstetrics and gynecology-will be counted. Those physicians engaged solely in administration, research, and teaching will be excluded. Adjustments for the following factors will be made in computing the number of full-timeequivalent (FTE) primary care physicians:

(1) Interns and residents will be counted as 0.1 full-time equivalent (FTE) physicians.

(11) Graduates of foreign medical schools who are not citizens or lawful permanent

residents of the United States will be cluded from physician counts.

(11i) Those graduates of foreign mec schools who are citizens or lawful permas residents of the United States, but do have unrestricted licenses to practice De cine, will be counted as 0.5 FTE physicia:

(b) Practitioners who are semi-retired, F operate a reduced practice due to infira or other limiting conditions, or who pro patient care services to the residents of area only on a part-time basis will be counted through the use of full-time equir lency figures. A 40-hour work week will used as the standard for determining to time equivalents in these cases. For pract tioners working less than a 40-hour week every four (4) hours (or 1 day) spent prov. ing patient care, in either ambulatory or to patient settings, will be counted as 0.1 FT: (with numbers obtained for FTE's rounded the nearest 0.1 FTE), and each physician pro viding patient care 40 or more hours a wel will be counted as 1.0 FTE physician. (F: cases where data are available only for the number of hours providing patient care in of fice settings, equivalencies will be provide in guidelines.)

(c) In some cases, physicians located with in an area may not be accessible to the population of the area under consideration. Ar lowances for physicians with restricted prac tices can be made, on a case-by-case basis However, where only a portion of the population of the area cannot access existing primary care resources in the area, a population group designation may be more appropriate (see part II of this appendix).

(d) Hospital staff physicians involved exclusively in inpatient care will be excluded. The number of full-time equivalent physicians practicing in organized outpatient departments and primary care clinics will be

'cluded, but those in emergency rooms will (c) Primary care professional(s) in the conexcluded.

tiguous area are inaccessible to the popu(e) Physicians who are suspended under lation of the area under consideration beProvisions of the Medicare-Medicaid Anti- cause of specified access barriers, such as: raud and Abuse Act for a period of eighteen (i) Significant differences between the deonths or more will be excluded.

mographic (or socio-economic) characteris. 4. Determination of Unusually High Needs for tics of the area under consideration and srimary Medical Care Services.

those of the contiguous area, indicating that 1. An area will be considered as having un- the population of the area under considerusually high needs for primary health care ation may be effectively isolated from nearcervices if at least one of the following cri- by resources. This isolation could be indiseria is met:

cated, for example, by an unusually high pro: (a) The area has more than 100 births per portion of non-English-speaking persons. ear per 1,000 women aged 15-44.

(11) A lack of economic access to contig- (b) The area has more than 20 infant deaths uous area resources, as indicated particuer 1,000 live births.

larly where a very high proportion of the (c) More than 20% of the population (or of population of the area under consideration is 1 households) have incomes below the pov- poor (i.e., where more than 20 percent of the -rty level.

population or the households have incomes 5. Determination of Insufficient Capacity of below the poverty level), and Medicaid-covEristing Primary Care Providers.

ered or public primary care services are not - An area's existing primary care providers available in the contiguous area. will be considered to have insufficient capac- C. Determination of Degree of Shortage. ity if at least two of the following criteria Designated areas will be assigned to dePare met:

gree-of-shortage groups, based on the ratio (a) More than 8,000 office or outpatient vis- (R) of population to number of full-time its per year per FTE primary care physician equivalent primary care physicians and the IT serving the area.

presence or absence of unusually high needs (b) Unusually long waits for appointments for primary health care services, according for routine medical services (1.e., more than to the following table: 7 days for established patients and 14 days for new patients).

High needs not indi

cated 2: (c) Excessive average waiting time at pri

High needs indicated il mary care providers (longer than one hour

Group 1

No physicians No physicians; or 1 where patients have appointments or two

R25,000 si hours where patients are treated on a first

Group 2 ..
R25,000

5,000>R24,000 * come, first-served basis).

Group 3 5,000>R24,000 4,000>R23,500 (d) Evidence of excessive use of emergency Group 4 4,000 R23,500 3,500_R23,000 & room facilities for routine primary care. !

(e) A substantial proportion (2/3 or more) of D. Determination of size of primary care phyAs the area's physicians do not accept new pa

sician shortage. Size of Shortage (in number tients.

of FTE primary care physicians needed) will (1) Abnormally low utilization of health be computed using the following formulas: services, as indicated by an average of 2.0 or

(1) For areas without unusually high need less office visits per year on the part of the

or insufficient capacity: - area's population.

Primary care physician shortage=area popu6. Contiguous Area Considerations.

lation/3,500 - number of FTE primary care Primary care professional(s) in areas con- physicians tiguous to an area being considered for des

(2) For areas with unusually high need or ignation will be considered excessively dis

insufficient capacity: tant, overutilized or inaccessible to the pop- Primary care physician shortage=area popuulation of the area under consideration if lation/3,000 - number of FTE primary care one of the following conditions prevails in

physicians each contiguous area: (a) Primary care professional(s) in the con

Part 11- Population Groups tiguous area are more than 30 minutes travel A. Criteria. time from the population center(s) of the 1. In general, specific population groups area being considered for designation (meas- within particular geographic areas will be ured in accordance with paragraph B.1(b) of designated as having a shortage of primary this part).

medical care professional(s) If the following (b) The contiguous area population-to-full- three criteris are met: time-equivalent primary care physician (a) The area in which they reside is rationratio is in excess of 2000:1, indicating that al for the desy of primary medical care practitioners in the contiguous area cannot services, as in purngrah of part be expected to help alleviate the shortage I of this appena situation in the area being considered for (b) Access bar designation.

group from use on

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care providers. Such barriers may be economic, linguistic, cultural, or architectural, or could involve refusal of some providers to accept certain types of patients or to accept Medicaid reimbursement.

(c) The ratio of the number of persons in the population group to the number of primary care physicians practicing in the area and serving the population group is at least 3,000:1.

2. Indians and Alaska Natives will be considered for designation as having shortages of primary care professional(s) as follows:

(a) Groups of members of Indian tribes (as defined in section 4(d) of Pub. L. 94-437, the Indian Health Care Improvement Act of 1976) are automatically designated.

(b) Other groups of Indians or Alaska Natives (as defined in section 4(c) of Pub. L. 94 437) will be designated if the general criteria in paragraph A are met.

B. Determination of Degree of Shortage.

Each designated population group will be assigned to a degree-of-shortage group, based on the ratio (R) of the group's population to the number of primary care physicians serving it, as follows: Group 1-No physicians or R>5,000. Group 25,000>R24,000. Group 3–4,000>R23,500. Group 43,500>R23,000.

Population groups which have received "automatic" designation will be assigned to degree-of-shortage group 4 if no information on the ratio of the number of persons in the group to the number of FTE primary care physicians serving them is provided.

C. Determination of size of primary care physician shortage. Size of shortage (in number of primary care physicians needed) will be computed as follows:

Primary care physician shortage=number of persons in population group/3,000 - number of FTE primary care physicians

cians is computed as in part 1, sectic paragraph 3 above.)

2. Determination of Degree of Shortage.

Designated correctional institutions be assigned to degree-of-shortage ca based on the number of inmates andoratio (R) of internees to primary care per cians, as follows: Group 1-Institutions with 500 or more

mates and no physicians. Group 2-Other institutions with no per

cians and institutions with R=2,000. Group 3–Institutions with 2,000>R21,000

B. Public or Non-Profit Medical Facilities. 1. Criteria.

Public or non-profit private medical fi ties will be designated as having a shora of primary medical care professional(s) if:

(a) the facility is providing primary Dec cal care services to an area or populati group designated as having a primary can professional(8) shortage; and

(b) the facility has insufficient capacity : meet the primary care needs of that area si population group.

2. Methodology

In determining whether public or nonprot private medical facilities meet the criter) established by paragraph B.1 of this Pari the following methodology will be used:

(a) Provision of Services to a Designated As of Population Group.

A facility will be considered to be prors ing services to a designated area or population group if either:

(1) A majority of the facility's primary care services are being provided to residenta of designated primary care professionalia shortage areas or to population groups des ignated as having a shortage of primary care professional(s); or

(ii) The population within a designated primary care shortage area or population group has reasonable access to primary care serv ices provided at the facility. Reasonable access will be assumed if the area within which the population resides 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.

Migrant health centers (as defined in section 319(a)(1) of the Act) which are located in areas with designated migrant population groups and Indian Health Service facilities 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 the area or population it serves if at least two of the following conditions exist at the facility:

(i) There are more than 8,000 outpatient visits per year per FTE primary care physi

Part III- Facilities A. Federal and State Correctional Institutions.

1. Criteria.

Medium to maximum security Federal and State correctional institutions and youth detention facilities will be designated as having a shortage of primary medical care professional(s) 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. (Here 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 who left before the end of the year; the number of FTE primary care physi

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