HPSA and MUA/P Program Overview
This overview is intended to provide basic information on some of the fundamental concepts of Health Professional Shortage Area (HPSA) and Medically Underserved Area/Population (MUA/P) designations. This information is not intended to be all inclusive but should provide the background information needed to understand the purpose of, general criteria for, and applications of HPSA and MUA/P designations. More detailed information is available at the federal Health Resources and Services Administration Shortage Designation Webpage.
HPSAs and MUA/Ps are areas, population groups, and facilities designated by the United States Department of Health and Human Services as having met criteria indicating a significant need for additional primary health care resources. The purpose of these designations is to identify areas of greatest unmet primary health care need, such that limited resources can be prioritized and directed to those areas to assist in addressing that need.
An area, population group, or facility designated as a HPSA or MUA/P has specific programs made available to it targeted at enhancing primary care infrastructure through recruitment and retention of health care providers and support for primary health care facilities. Federal and State programs utilizing shortage designations as criteria for eligibility include: National Health Service Corps, State Loan Repayment Program, NURSE Corps, Federally Qualified Health Center and Health Center Look-Alike Certification, Medicare Incentive Payment Program, CMS Rural Health Clinics Program, J-1 Visa Waiver and the National Interest Waiver Programs, as well as scoring preferences for various Title VII and VIII grants.
HPSA designations identify a shortage of either primary medical care, dental health or mental health providers in a specific geographic area, a population group, or a health care facility. Primary medical care HPSAs are designated if there is an established shortage of primary care physicians. Dental care HPSAs are granted if there is an established shortage of general dentists and pedodontists (also considering the number of dental auxiliaries). Mental health care HPSAs are granted if there is an established shortage of psychiatrists, or a shortage of psychiatrists, psychologists, clinical social workers, psychiatric nurse specialists, and marriage and family therapists.
Within each discipline, there are three types of HPSA designations. HPSA designations can be for geographic areas based on the ratio of an area's resident civilian population (the total population excluding those in institutions) to the number of full time equivalent (FTE) providers in the area. HPSAs can be for population groups based on the ratio of a particular population group (i.e. the low-income population of an area) to the number of FTE providers serving that population group (i.e. those physicians seeing Medicaid patients and/or low-income uninsured patients paying on a sliding fee scale). HPSAs can also be specific to a facility - designations granted to the facility itself based on unique criteria depending on the type of facility (general public or non-profit facility, state or federal correctional institution, state or county mental hospital, Federally Qualified Health Center, Rural Health Clinic), or Indian Health Service, tribally operated, or urban Indian health programs (ITUs).
The basic criteria for geographic and population group HPSA designations include:
- Be a Rational Service Area (RSA): The service area to be designated must be comprised of an area rational for the delivery of health services. According to the established criteria, a rational service area can be a single county, a group of counties with population centers within 30 minutes of each other (for primary medical care, dental health care and mental health care), or portions of a county or counties. A partial county service area must consist of an established neighborhood, areas having similar demographic characteristics isolating them from surrounding regions, areas with physical barriers isolating them from surrounding regions, or areas linked by distinct travel patterns.
- Contiguous Areas Analysis: The contiguous areas to the proposed service area must not contain primary care resources accessible to the population of the proposed service area. Primary care resources in contiguous areas must be overutilized, excessively distant, or otherwise inaccessible to the population of the proposed service area.
- The ratio of population to providers within the service area must demonstrate a severe shortage of primary care providers to the area.
- For primary medical care HPSAs the ratio must be at least 3,500:1 for a geographic designation, 3,000:1 for a geographic designation with unusually high needs, or 3,000:1 for a population group designation.
- For dental care HPSAs the ratio must be at least 5,000:1 for a geographic designation, 4,000:1 for a geographic designation with unusually high needs, or 4,000:1 for a population group designation.
- For mental health care HPSAs the ratio must be at least 30,000:1 for psychiatrists only, 9,000:1 for core mental health care providers only, or 6,000:1 for core mental health providers and 20,000:1 for psychiatrists for a geographic designation. For a geographic designation with unusually high needs, the ratio must be at least 20,000:1 for psychiatrists, 6,000:1 for core mental health providers including psychiatrists, or 4,500:1 for core mental health providers and 15,000:1 for psychiatrists. For a population group designation, the ratio must be at least 20,000:1 for psychiatrists, 6,000:1 for core mental health providers including psychiatrists, or 4,500:1 for core mental health providers and 15,000:1 for psychiatrists.
Once designated, HRSA scores HPSAs on a scale of 0-25 for primary medical care and mental health, and 0-26 for dental health, with higher scores indicating greater need. The requirements for facility HPSA designations are specific to the facility type and discipline of interest. For more information on facility HPSA designations, please utilize this HPSA and MUA/P Contact Information.
A Medically Underserved Area (MUA) is a rational service area with a demonstrable shortage of primary healthcare resources relative to the needs of the entire population within the service area. A Medically Underserved Population (MUP) is a group of people within a rational service area facing barriers to healthcare access and having a demonstrable shortage of primary healthcare resources relative to the needs of that specific population group.
The established criteria for determining eligibility of a rational service area for MUA or MUP designation involve application of the Index of Medical Underservice (IMU) to data specific to the rational service area. The IMU is a scale from 0 to 100 (with 0 corresponding to complete underservice and 100 corresponding to the highest level of service) with scores on the scale determined by adding weighted values for 4 variables. The variables scored for the IMU include the rate of primary medical care physicians per 1,000 population, the infant mortality rate, the percentage of the population with incomes below the poverty level, and the percentage of the population age 65 years or older.
Data on each of the 4 IMU variables is required in determining eligibility for MUA and MUP designations. The major difference between the data collected for an MUA and that collected for an MUP evaluation is in the provider FTE to 1,000 population variable. For an MUA, provider FTE information should be collected for all primary care physicians in the area. For an MUP, provider FTE information is only necessary for providers serving the population group of interest. Some areas not meeting the MUA/P regular criteria may still qualify as a special type of MUA/P, if:
- there is an unusual, documented local conditions that prevent access to, or demonstrate the lack of, personal health services. A state governor can recommend, through the state Primary Care Office, an exceptional MUP for a population that demonstrates need but does not meet the regular criteria for designation.
- State Governor’s Certified Shortage Area for the establishment of Rural Health Clinics, based on HRSA-approved and state-established shortage plan.
Such requests must also include a written recommendation for designation from the governor or other chief executive officer of the state (or state-equivalent) and local health official, as well as any supporting data.
The methodological differences between HPSA and MUA/P designations are explained in the sections above. There are two other main differences between these designation categories: the programs requiring the designations for eligibility and the review schedule for renewal of designations.
The type of designation (i.e. Geographic HPSA, Population Group HPSA, MUA, MUP, etc.) required for eligibility to programs like the National Health Service Corps, the Federally Qualified Health Center program, or the Certified Rural Health Clinic program varies from program to program. Information on the designation requirements for some of the more asked about programs is available here: Programs Utilizing HPSA and MUA/P Designations.
The other major difference between HPSA and MUA/P designations is the federally established review cycle required for HPSA designations, but not required for MUA or MUP designations. According to current regulations, once an area has been designated an MUA or an MUP, that area remains designated with no required review. MUA and MUP designations can be updated with new information (an approach that can be taken if an area is seeking to utilize the Rural Health Clinic program and needs an MUA designation that has been updated within the last four years) but update of the designations is not required.