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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.

$5.3 Procedures for designation of health professional(s) shortage

areas.

(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.

(b) In addition, any agency or m vidual may request the Secretary designate (or withdraw the designat of) a particular geographic area, p lation group, or facility as a h professional(s) shortage area. Each quest will be forwarded by the S retary to the appropriate R SHPDA, and Governor, who wil asked to review it and offer their ommendations, if any, within 30 day An information copy will also be ma available to other interested partia upon request, for their use in provid comments or recommendations to > Secretary and/or to the appropriat HSA, SHPDA, or Governor.

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

(d) After review of the available formation and consideration of th comments and recommendations sub mitted, the Secretary will designat health professional(s) shortage area and withdraw the designation of an areas which have been determined E longer to have a shortage of health professional(s).

§5.4 Notification and publication d designations and withdrawals.

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(a) The Secretary will give writte notice of the designation (or with. drawal of designation) of a health, 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 in 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 so

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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 defined as follows:

(1) If the number of new inmates per year and the average length-of-stay are not specified, or if the information provided does not indicate that intake medical examinations are routinely performed upon entry, thenNumber of internees-average number of inmates.

(ii) If the average length-of-stay is specified as one year or more, and intake medical examinations are routinely performed upon entry, then-Number of internees-average number of inmates+(0.3)xnumber of new inmates per year.

(iii) If the average length-of-stay is specified as less than one year, and intake examinations are routinely performed upon entry, then-Number of internees-average number of inmates+(0.2)x(1+ALOS/2)xnumber of new inmates per year where ALOS-average length-of-stay (in fraction of year). (The number of FTE primary care physicians is computed as in part I, section B, paragraph 3 above.)

2. Determination of Degree of Shortage. Designated correctional institutions will be assigned to degree-of-shortage groups based on the number of inmates and/or the ratio (R) of internees to primary care physicians, as follows:

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

Group 2-Other institutions with no physicians and institutions with R greater than (or equal to) 2,000:1.

Group 3-Institutions with R greater than (or equal to) 1,000:1 but less than 2,000:1. 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 Primary Medical Care Services.

(a) The following areas will be considered rational areas for the delivery of primary medical care services:

(1) A county, or a group of contiguous counties whose population centers are within 30 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 greater than 30 minutes to such re

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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 population & differing health service requirements d ious age-sex population groups will be = puted using the table below of visit raz 12 age-sex population cohorts. The tou pected visit rate will first be obtaine multiplying each of the 12 visit rates table by the size of the area population v. in that particular age-sex cohort and sic the resultant 12 visit figures together. total expected visit rate will then be div by the U.S. average per capita visit m 5.1, to obtain the adjusted population for.

area.

Age groups

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

(i) 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.

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(ii) 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 population-0.25×(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:

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

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

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

(iii) Those graduates of foreign med: schools who are citizens or lawful perman residents of the United States, but do 1 have unrestricted licenses to practice me cine, will be counted as 0.5 FTE physician

(b) Practitioners who are semi-retired, v operate a reduced practice due to infirm or other limiting conditions, or who provi patient care services to the residents of area only on a part-time basis will be counted through the use of full-time equin lency figures. A 40-hour work week will used as the standard for determining f time equivalents in these cases. For pract tioners working less than a 40-hour weel every four (4) hours (or 1⁄2 day) spent provi ing patient care, in either ambulatory or i patient settings, will be counted as 0.1 F (with numbers obtained for FTE's rounded the nearest 0.1 FTE), and each physician pro viding patient care 40 or more hours a weel will be counted as 1.0 FTE physician. (Fe) cases where data are available only for the number of hours providing patient care in of fice settings, equivalencies will be provided in guidelines.)

(c) In some cases, physicians located with in an area may not be accessible to the popu lation of the area under consideration. A lowances for physicians with restricted prac tices can be made, on a case-by-case basis. However, where only a portion of the popu lation of the area cannot access existing pri mary care resources in the area, a popu lation 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

*2cluded, but those in emergency rooms will excluded.

(e) Physicians who are suspended under ovisions of the Medicare-Medicaid Antiraud and Abuse Act for a period of eighteen onths or more will be excluded.

2.4. Determination of Unusually High Needs for Primary Medical Care Services.

An area will be considered as having unasually high needs for primary health care Lervices if at least one of the following crieria is met:

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

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

(c) More than 20% of the population (or of all households) have incomes below the povrty 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 Sare met:

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

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(b) Unusually long waits for appointments for routine medical services (i.e., 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 professional(s) 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 professional(s) in the contiguous area are more than 30 minutes travel time from the population center(s) of the area being considered for designation (measured in accordance with paragraph B.1(b) of this part).

(b) The contiguous area population-to-fulltime-equivalent primary care physician ratio is in excess of 2000:1, indicating that practitioners in the contiguous area cannot be expected to help alleviate the shortage situation in the area being considered for designation.

(c) Primary care professional(s) in the contiguous area 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. This isolation could be indicated, for example, by an unusually high proportion of non-English-speaking persons.

(ii) A lack of economic access to contiguous area resources, as indicated particularly where a very high proportion of the population of the area under consideration is poor (i.e., where more than 20 percent of the population or the households have incomes below the poverty level), and Medicaid-covered or public primary care services are not available in the contiguous area.

C. Determination of Degree of Shortage. Designated areas will be assigned to degree-of-shortage groups, based on the ratio (R) of population to number of full-time equivalent primary care physicians and the presence or absence of unusually high needs for primary health care services, according to the following table:

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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. 94437) 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 2-5,000>R24,000.

Group 3 4,000>R<3,500.
Group 4-3,500>R<3,000.

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

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

cians is computed as in part I, section paragraph 3 above.)

2. Determination of Degree of Shortage. Designated correctional institutions be assigned to degree-of-shortage gr based on the number of inmates and/or ratio (R) of internees to primary care ph cians, as follows:

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

Group 2-Other institutions with no phys cians and institutions with R22,000. Group 3-Institutions with 2,000>R≥1,000.

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

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

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

(b) the facility has insufficient capacity 2 meet the primary care needs of that ares population group.

2. Methodology

In determining whether public or nonprofi private medical facilities meet the criteri established by paragraph B.1 of this Part the following methodology will be used:

(a) Provision of Services to a Designated Ara or Population Group.

A facility will be considered to be provi ing services to a designated area or popu lation group if either:

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

(ii) The population within a designated pri- Į mary care shortage area or population group has reasonable access to primary care services provided at the facility. Reasonable ac cess 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

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