HRSA Hopes Committee Will Translate a Tower of Babel

Cheryl Clark, July 21, 2010

Does anyone really understand the reason why there are so many definitions for the terms "medically underserved area" and "health professional shortage area?"

As any healthcare provider who ever submitted a funding application knows, the definitions of those phrases vary depending on the agency, the program, poverty rates, racial or ethnic makeup, various ratios and percentages and distances from one place to another. It's a Tower of Babel out there.

The definitions can change depending on whether the provider is a hospital, a clinic that is "federally qualified," a doctor, a nurse or an allied health professional, and how many people in the region are considered uninsured, or older, and what boundaries are used to define a region. 

Infant mortality, rates of fertility and excessive wait times can contribute to the confusing formula as well. Population shifts are also a concern, as some definitions rely on counts from 10-year-old census surveys.

"No one uses the same definition," complains Nina Antonetti, director of Telehealth for the Marshfield Clinic system in Marshfield, Wisconsin, who says she counted no fewer than 120 definitions of "rural," just within the Health Resources and Services Administration.

But billions of dollars are at stake based on these definitions, so it's important to make sure they are meaningful.

That's why HRSA tried in 1998 and 2008 to standardize the definitions, but it got so many letters of complaint that the agency gave up.  No matter what the HRSA proposed, some important part of the country would get left out, and another that some insisted should be excluded, would get in.

According to the Federal Register May 11, "In both cases, many public comments were received, and the concerns expressed resulted in an HRSA decision to reconsider and develop a new proposal to be published at a later date; no final revised rule has yet been adopted."

But here it is, 2010, and the Obama administration, known for venturing where others have failed, is trying it again, this time with a different tactic.

Last week, Secretary of Health and Human Services Kathleen Sebelius appointed 28 people across the country to a "negotiated rulemaking" committee ( "to review and update the criteria used to define medically underserved areas and health professional shortage areas."

The idea is that with a "negotiated" process, some of the pitfalls and contentiousness will be sorted out by consensus, without HRSA holding rancorous proceedings.  And the HRSA process of actually making the rule will go much more smoothly.

At least that's the hope.

The geographically diverse appointees, charged with muddling through various definition scenarios, hail from Hawaii to New Hampshire and from Alaska to Georgia. They represent community health centers, hospitals and clinics in rural areas, special populations with unique healthcare needs, and technical experts in research dealing with healthcare professions, access and statistics.

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