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Tools for Monitoring the Health Care Safety Net

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Rural Health Care Safety Nets (continued)

Shortage Area Designation and Program Eligibility

Many rural areas may have considerable shortages of physicians, physician assistants, nurse practitioners, dentists, mental health providers, registered nurses, and other health care professionals. For example, the physician-to-population ratio in metropolitan counties in 1997, well over 200 physicians per 100,000 population, was two to four times the ratio in nonmetropolitan counties (Farley et al., 2002). The physician-to-population ratio in nonmetropolitan counties ranged from a low of 54 per 100,000 in frontier and remote counties with no town to a high of 170 per 100,000 in remote counties with a city of 10,000 or more (Farley et al., 2002). A shortage of providers affects all residents in the shortage area because of a lack of access to a range of needed services. For example, Parchman and Culler (1999) found that living in a primary care health professional shortage area increased the probability of hospitalization for conditions considered to be preventable by adequate primary care (ambulatory care sensitive admissions).

Several Federal programs, including the Rural Health Clinics Program, the National Health Service Corps, and Community Health Center Grants, help to recruit, stabilize, and support rural providers and the provision of services in rural communities. To target these programs to areas with shortages of health care providers and other access-related problems, the Federal Government has two shortage area designation systems: Health Professional Shortage Areas (HPSAs) and Medically Underserved Areas/Medically Underserved Populations (MUAs/MUPs). These two shortage area designation systems are now used by more than 34 Federal programs to determine eligibility and/or funding preference (U.S. Department of Health and Human Services, 2002). A third shortage area designation system, Governor-Designated Shortage Areas (GDSAs), can be used by the States to certify Rural Health Clinics, although it is used much less frequently than the HPSA or MUA designation systems (Gale and Coburn, 2003). As background for State and local leaders and others interested in understanding and supporting the rural health care safety net, we will discuss the different types of shortage area designations and how they are used by specific Federal programs of interest to support and develop rural safety net providers and services.

The majority of nonmetropolitan counties are classified as having a shortage of health professionals by virtue of their designation as full- or partial-county HPSAs or MUAs/MUPs. Only 9.6 percent of nonmetropolitan counties have no designation as either an HPSA or MUA/MUP, with 36 percent designated as either an HPSA or MUA/MUP, and 54 percent designated as both (either full-county or partial-county designation) (Farley et al., 2002).

Health Professional Shortage Area

The HPSA designation system was developed in the 1970s for use in allocating placements under the National Health Service Corps, a program designed to recruit and retain health professionals in underserved areas. An HPSA is a geographically defined area designated by the Federal Government as having inadequate access to health care according to specific criteria. An area can be designated as an HPSA as a result of inadequate access to one or more of the following categories of care:

  • Primary care (including family and general practitioners, pediatricians, obstetricians, and general internists in allopathic or osteopathic practice).
  • Mental health care.
  • Dental care.

To be designated as having a shortage of primary care services, a geographic area must:

  • Be a rational service area for the delivery of care.
  • Exceed a specified ratio of population to full-time-equivalent providers.
  • Lack access to health care in contiguous areas due to overutilization, excessive distance, or inaccessibility of care to the population of the area under consideration.

A shortage area can be designated at the county (whole-county HPSA) or sub-county (partial-county HPSA) level. Because the Federal criteria for HPSA designation depend on census data, partial county HPSAs are established using census tracts or census civil divisions. Within these areas, shortages can apply to:

  • An entire population (geographic designation).
  • An underserved subpopulation within a geographic area (population designation). (Eligible populations include low-income populations; Medicaid-eligible populations; migrant and seasonal workers and their families; Native Americans; or other populations isolated from access due to language barriers, cultural barriers, or disabilities).
  • Public or non-profit facilities located outside an HPSA but which provide access to health care for residents in an adjoining HPSA.
  • Federally recognized tribes.
  • Federal and State correctional facilities or State mental hospitals.

To be designated as an HPSA, an area must exceed a population to full-time equivalent provider ratio of 3,000 to 3,500 or more people per primary care physician of 4,000 to 5,000 or more people per dentist. The lower threshold applies to areas with unusually high need for or insufficient capacity of existing providers. Mental health HPSAs are required to meet varying population-to-core mental health professional ratios depending on the mix and type of mental health professionals practicing in the area.

Medically Underserved Area/Medically Underserved Population

The MUA/MUP designation system was developed to identify areas where Community and Migrant Health Centers could locate. MUA/MUP designations are similar to primary care HPSAs, although they have less rigorous criteria. As a result of the less rigorous criteria used to designate MUAs, communities that may not qualify for Federal HPSA designation may obtain MUA designation, thereby qualifying it for some Federal safety net programs. An MUA designation can be granted for an identified vulnerable population when a geographic designation is not possible.

To be designated as an MUA, an Index of Medical Underservice (IMU) is calculated for the defined geographic service area. The calculation of an area's IMU uses four variables:

  • Ratio of primary medical care physicians per 1,000 population.
  • Infant mortality rate.
  • Percentage of the population with incomes below the poverty level.
  • Percentage of the population age 65 or older.

The value of each of these variables for the service area is converted to a weighted value, according to established criteria, and the four values are summed to obtain the area's IMU score. The IMU is based on a scale of 0 to 100, where 0 represents completely underserved and 100 represents best served or least underserved. Those with an IMU score of less than 62.0 are designated as MUAs.

The designation of an MUP uses a similar process involving the application of the IMU to data for an underserved population group within an area of residence to obtain a score for that group. Population groups eligible for MUP designation are those with economic barriers (e.g., low-income or Medicaid-eligible populations), or cultural and/or linguistic access barriers to primary medical care services. The population used in the calculation of the IMU is the population of the specific group being considered for designation rather than the total resident population of the area, and the number of full-time equivalent primary care physicians would include only those serving the specific population. If the application of the IMU results in a score of 62.0 or less, the population group qualifies for designation as an MUP.

Governor-Designated Service Areas

States may develop their own standards for the designation of shortage areas that do not meet either the HPSA or MUA/MUP standards. The methodology and data used to develop Governor-Designated Service Areas (GDSAs) must be reviewed and approved by the Shortage Designation Branch staff within the Bureau of Health Professions at the Health Resources and Services Administration. GDSAs are used primarily for the Rural Health Clinic program (Gale and Coburn, 2003).

Shortage Designation Process

Most commonly, State-level shortage area designation activities for HPSAs, MUAs/MUPs, and GDSAs are coordinated within an agency of State Government. Information on the designated shortage areas or the designation status of a given area or population within each State can be obtained from these agencies or organizations. In addition, the Bureau of Health Professions Shortage Designation Branch in the Health Resources and Services Administration maintains online HPSA and MUA/MUP databases on its Web site (

According to Federal regulations, HPSAs must be re-designated every 3 years. MUA and MUP designations do not have Federal requirements to be updated periodically. As a result, many MUA and MUP sites were designated over 5 to 10 years ago. This may cause problems for RHCs, whose certification status is based on their location in an MUA. The Balanced Budget Act of 1997 requires an RHC to be located in a shortage area whose designation (or update) occurred within the past 3 years. RHCs located in areas with a designation status or update greater than 3 years old may be at risk for loss of their certification, unless they qualify for an exception as an "essential provider."

Program Eligibility

Although the HPSA, MUA/MUP, and GDSA designations serve similar purposes, all legislation authorizing Federal programs affecting rural areas does not use the same designation criteria. The following list describes some of the Federal programs that have direct implications for rural safety net providers and the specific Federal shortage area designations used to determine eligibility for participation in the program (Washington State Department of Health, 2002):

  • The National Health Service Corps (NHSC) provides scholarship and loan repayments to health professionals who agree to serve in the NHSC in HPSAs.
  • The Area Health Education Center Program gives special consideration to centers that would serve HPSAs with higher percentages of underserved minorities, and gives funding priority to centers providing substantial training experience in HPSAs.
  • The Rural Health Clinics Program provides enhanced Medicare and Medicaid reimbursement for services provided by qualifying providers practicing in certified clinics in rural HPSAs, MUAs, or GDSAs.
  • Medicare Incentive Payment for Physician Services Furnished in HPSAs gives a 10 percent bonus to physicians providing Medicare-reimbursable services only within geographic HPSAs.
  • Medicare Reimbursement for Teleconsultations is provided for teleconsultations originating in nonmetropolitan counties or in primary care geographic HPSAs in metropolitan counties.
  • Public Health Service Grant Programs provide funding preference for health professionals training programs in HPSAs and MUA/MUPs.
  • The Community Health Center Program provides grant funds to support the planning, development, or operation of community health centers serving designated MUAs or MUPs.
  • FQHCs provide enhanced Medicare and Medicaid reimbursement for services provided by qualified facilities, if they meet the definition of a community health center contained in Section 330 of the Public Health Service Act, but are not funded under that section, and are serving a designated MUA or MUP.
  • The J-1 Visa Waiver Program allows for Foreign Medical Graduates or International Medical Graduates to remain in the United States upon completion of their training, if they practice in an HPSA or MUA/MUP (whole county).

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Special Issues for Rural Safety Nets

Gaps in the Rural Safety Net

In addition to concerns about primary care, access to mental and oral health services is a growing concern of many rural health advocates (O'Grady, Mueller, and Wilensky, 2001; U.S. Department of Health and Human Services, 2002). In general, few, if any, mental health providers and dentists maintain an "open door" policy in rural areas.

The shortage of rural dentists leaves a considerable gap in rural safety net services. In most States, dental hygienists are now allowed to provide a variety of services independently if they are practicing in a public health setting. In many rural communities, the most promising approach to improving access to dental services is to place a dental hygienist in a school-based clinic.

Similarly, there is a chronic shortage of mental health providers in rural areas. Community Mental Health Centers (CMHCs) are often thought to have a safety net mission, but a recent study has shown that it is increasingly difficult for these centers to provide free or low-cost care to patients whose mental illnesses are not "serious and persistent" (Hartley et al., 2002). Most funding provided to CMHCs is designated for adults with serious and persistent mental illnesses and seriously emotionally disturbed children. Rural residents with mental health conditions that do not meet this severity threshold may be put on long waiting lists or are treated by primary care safety net providers.

Geographic Accessibility

Rural residents travel greater distances for health care than do their urban counterparts (Hartley, Quam, and Lurie, 1994; Edelman and Menz, 1996; Schur and Franco, 1999). In explicating a now classic model of access to health care, Andersen et al. (1983) note:

"Equity of access may be said to exist when services are distributed on the basis of people's need for them."

The dilemma in understanding the impact of travel time and distance on access to care is in distinguishing between need and demand (Connor, Kralewski, and Hillson, 1994). Since rural residents are accustomed to traveling greater distances for shopping, entertainment, school, church, and a variety of other services, it could be argued that distance is not a major barrier to access, except, perhaps, in the case of emergencies where timely care affects outcomes. At the opposite end of the acuity spectrum, preventive care may also be affected by distance, as rural residents may simply not choose to seek such care, due to the inconvenience of travel time (Slifkin, 2002). While we have evidence that rural safety net patients will delay care for financial reasons, preferring to put off the embarrassment of medical indigence, the added inconvenience of long travel time may compound the financial barrier (Blazer et al., 1995).

The direct effect of transportation difficulties on access to safety net care is unclear and somewhat more complex than is generally acknowledged. In a community health assessment in rural Maine, physicians reported transportation as a major barrier to care, yet a household survey failed to corroborate this finding from the patient's perspective. Further investigation discovered that, for many safety net families, a variety of complications including child care, an unreliable car, and the unpredictability of life at the subsistence level may cause cancellation of medical appointments. If a family in this situation has a telephone, they may call the physician's office and report that "car trouble" makes it necessary to cancel an appointment. The physician concludes that transportation is a major issue, whereas the full story was simply too complicated for the patient to report (Sunrise HC Coalition, 1997).


"...rural places with low population density continue to be characterized by a lessened sense of confidentiality..." (Hoyt et al., 1997)

The issue of confidentiality as a barrier to seeking health care is most frequently identified with respect to mental health care. In small towns, it is often reported that "everybody knows everybody else's business," such that if a pickup truck is seen parked outside the mental health center, everyone will know that the owner has a problem. Although it is often accepted as fact that the stigma of mental illness is greater in rural areas and may discourage affected individuals from seeking care, research findings confirming this effect are few and not conclusive. Although Hoyt and colleagues confirmed a greater influence of stigma in some rural populations, a more recent study found that "those in rural areas are significantly less likely to report experiencing stigma" (Kessler et al., 2001, p. 999). Often overlooked in discussions of the rural confidentiality issue is the challenge for rural providers when their patients are their neighbors. The need to maintain professional distance and to maintain total patient confidentiality can be exhausting for some rural mental health practitioners.

Because of the stigma of medical indigence, these confidentiality issues also apply to the primary care setting. If a community health center is known to deliver care to the poor, individuals seeking care there clearly identify themselves to the community as being poor. Moreover, in many rural communities the agrarian value of self-reliance exacerbates the stigma of seeking free or reduced cost care. While knowledge about an individual's specific medical problems is no less private in a rural setting, knowledge of his or her financial situation and dependence on publicly funded care may be made quite public by the mere fact of seeking care.

One solution to the privacy of care seeking may simply be to locate primary care in a site where those with commercial health insurance also seek care. A primary care clinic attached to a hospital, with entry near the emergency room, is one way to achieve this. Also, Rural Health Clinics often serve the entire community, with substantial numbers of insured patients, so stigma and confidentiality may be lessened when an RHC is the safety net provider.

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Assessing and monitoring the safety net in rural communities requires an understanding of the ways in which rural populations and rural providers differ from their urban counterparts. Rural communities are less likely to have traditional safety net providers, but may have special types of providers found only in rural areas, such as CAHs and RHCs, and may rely more on the informal safety net. Services provided by these types of providers may be difficult to quantify. Understanding the range of available programs and the different ways that Federal programs define "rural" may help communities determine which Federal programs might be appropriate to apply for in seeking outside resources to help fund safety net services.

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Andersen R, McCutcheon L, Aday L, et al. Exploring dimensions of access to medical care. Health Serv Res 1983;18(1):49-74.

Baer LD, Smith LM. Nonphysician professionals and rural America. In: Ricketts T, editor, Rural Health in the United States. New York: Oxford University Press; 1999.

Blanchfield B, Randall E. Data sources to study uncompensated care provided by hospitals. Bethesda: Project Hope, Walsh Center for Rural Health Analysis, W series, Vol. 3. No.5; 2000.

Blazer D, Landerman L, Fillenbaum G, et al. Health services access and use among older adults in North Carolina: urban versus rural residents. Am J Public Health 1995 Oct;85(10):1384-90.

Connor R, Kralewski J, Hilson S. Measuring geographic access to medical care in rural areas. Med Care Rev 1994 Fall;51(3):337-77.

Eberhardt M, Ingram D, Makuc D. Urban and rural health chartbook. Health, United States, 2001. Hyattsville, Maryland: National Center for Health Statistics, 2001.

Edelman M, Menz B. Selected comparisons and implications of a national rural and urban survey on health care access, demographics, and policy issues. J Rural Health 1996 Summer;12(3):197-205.

Farley D, Shugarman L, Taylor P, et al. Trends in special Medicare payments and service utilization for rural areas in the 1990s. Santa Monica: The Rand Corporation; 2002. pp. 46-48.

Fishman LE. What types of hospitals form the safety net? Health Aff (Millwood) 1997 Jul-Aug 1997;16(4):215-22.

Gale J. Rural Hospital Flexibility Tracking Program Year 3 Report. Seattle: WWAMI Rural Health Research Center, University of Washington; 2002. Chapter 1: State approaches to the certification of necessary providers in the Rural Hospital Flexibility Program. Available at: Accessed May 7, 2003.

Gale J, Coburn A. The characteristics and roles of Rural Health Clinics in the United States: A chartbook. Portland: University of Southern Maine, Edmund S. Muskie School of Public Service, Institute for Health Policy, Maine Rural Health Research Center; 2003. Available at: Accessed May 6, 2003.

Hagopian A, Hart G. Rural Hospital Flexibility Program Tracking Project. Seattle: WWAMI Rural Health Research Center, University of Washington; 2002. Chapter 1: Introduction to the Rural Hospital Flexibility Program Year 1 Report. Available at: Accessed May 7, 2003.

Hartley D, Bird D, Lambert D, Coffin J. The role of community health centers as rural safety net providers. Working Paper #29. Portland: Maine Rural Health Research Center, University of Southern Maine; 2002.

Hartley D, Quam L, Lurie N. Urban and rural differences in health insurance and access to care. Rural Health 1994;10(2): 98-108.

Hoyt D, Conger R, Valde J, Weihs K. Psychological distress and help seeking in rural America. Am J Community Psychol 1997 Aug;25(4):449-70.

Lewin ME, Altman S, editors. America's health care safety net: intact but endangered. Committee on the Changing Market, Managed Care, and the Future Viability of Safety Net Providers. Washington (DC): National Academy Press; 2000.

Kessler R, Berglund P, Bruce M, et al. The prevalence and correlates of untreated serious mental illness. Health Serv Res 2001 Dec;36(6 Pt 1):987-1007.

Levitt L, Holve E, Wang J. Employer Health Benefits 2001 Annual Survey. Menlo Park: Henry J. Kaiser Family Foundation; 2001.

Medicare Payment Advisory Committee. Report to the Congress: Medicare in rural America. Washington, DC: Medicare Payment Advisory Committee; 2001. Available at: Accessed May 7, 2003.

Mohr P, Franco S, Blanchfield B, et al. Vulnerability of rural hospitals to Medicare outpatient reform. Health Care Financ Rev 1999 Fall; 21(1):1-18. Available at: Accessed May 7, 2003.

National Advisory Committee on Rural Health. A targeted look at the rural health care safety net. A report to the Secretary, U.S. Department of Health and Human Services; 2002. Available at: Accessed December 2002.

National Rural Health Association. Physician Recruitment and Retention, 1998. Available at: Accessed August 2, 2002.

National Rural Health Association. What's Different About Rural Health Care. Available: Accessed December 2, 2002.

O'Grady M, Mueller C, Wilensky G. Essential research issues in rural health: the state rural health directors' perspective. W Series Vol. 5 No. 1 Project Hope: The Walsh Center for Rural Health Analysis; 2002.

Parchman M, Culler S. Preventable hospitalizations in primary care shortage areas: an analysis of vulnerable Medicare beneficiaries. Arch Fam Med 1999 Nov-Dec; 8(6):487-91.

Perloff J, Kletke P, Fossett J. Which physicians limit their Medicaid participation, and why. Health Serv Res 1995 Apr; 30(1):7-26.

Ricketts T, Slifkin R, Silberman P. The Changing Market, Managed Care and the Future Viability of Safety Net Providers—Special Issues for Rural Providers. Background Paper for the Institute of Medicine. Chapel Hill: Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill; 1998.

Schur L, Franco S. Access to health care. In: Ricketts T, editor, Rural health in the United States. New York: Oxford University Press; 1999. p 25-37.

Slifkin R . Developing policies responsive to barriers to health care among rural residents: What do we need to know? J Rural Health 2002;18(S):233-41.

Sunrise Health Care Coalition. Washington County Community Health Needs Assessment, 1997 monograph. Maine Rural Health Research Center, University of Southern Maine.

Taylor P, Blewett L, Brasure M, et al. Small town health care safety nets: report on a pilot study. J Rural Health 2003 Spring;19(2):125-34.

U.S. Census Bureau. Urban and Rural Definitions. Available at: Accessed May 6, 2003.

U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions, Shortage Designations Branch. Health Professional Shortage Area Guidelines for Primary Medical Care/Dental Designation; 1995. Available at: Accessed May 7, 2003.

U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions, Shortage Designations Branch. (2002). Health Professional Shortage Areas. Available at: Accessed January 7, 2003.

U.S. Department of Health and Human Services. One Department Serving Rural America. HHS Rural Task Force Report to the Secretary; 2002.

U.S. Small Business Administration, Office of Economic Research. Rural and Urban Areas by Firm Size, 1990-1995 Available at: Accessed May 6, 2003.

What the Heck is AHEC? University of South Florida Web site. Available at: Accessed May 7, 2003.

Washington State Department of Health, Office of Community and Rural Health. A Guide to Federal Health Professional Shortage Area Designations in Washington State. Available at: Accessed January 7, 2002.

Washington State Department of Health. Guidelines for using rural-urban classification systems for public health assessment. Available at: Accessed August 2, 2002.

Wisconsin Department of Health and Family Services. Wisconsin J-1 Visa Waiver Program Description. Available at: Accessed May 7, 2003.

Ziller E, Kilbreth B. Health Insurance Coverage and Access to Care in Maine: Results of a Household Survey, 2002. A study conducted on behalf of the Governor's Office of Health Policy and Finance. Available from the Institute for Health Policy, Muskie School of Public Service, University of Southern Maine; 2003.

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Appendix A. Resources and Tools

Understanding and Using Rural Classification Systems

The following materials provide additional information on rural classification systems:

Ricketts T, Johnson-Webb K, Taylor P. Definitions of rural: A handbook for health policy makers and researchers. Chapel Hill: University of North Carolina at Chapel Hill, Cecil G. Sheps Center for Health Services Research. Available at: Accessed December 16, 2002.

Washington State Department of Health. Guidelines for using rural-urban classification systems for public health assessment. Available at: Accessed August 2, 2002.

Measuring Rurality page. Economic Research Service, U.S. Department of Agriculture Web site. Available at: (This site provides an overview of the various rural classification schemes, downloadable data files for major classification schemes, links to other resources.)

Health Care Financial Issues and the Impact on Rural Providers

The following materials provide a useful overview of financial issues related to the delivery of health care services in rural communities:

Lane S, Longstreth E, Nixon V. A Community Leader's Guide to Hospital Finance: Evaluating How A Hospital Gets and Spends Its Money. Boston: Brandeis University, The Center for Community Health, Research, and Action, The Access Project. Available at: Accessed December 16, 2002.

McBride T, Mueller K. Effects of Medicare payment on rural health care systems. J Rural Health 2002;18(S):147-63.

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Current as of September 2003


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