Health Resources and Services Administration:

Many Underserved Areas Lack a Health Center Site, and the Health Center Program Needs More Oversight

GAO-08-723: Published: Aug 8, 2008. Publicly Released: Sep 11, 2008.

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Health centers funded through grants under the Health Center Program--managed by the Health Resources and Services Administration (HRSA), an agency in the U.S. Department of Health and Human Services (HHS)--provide comprehensive primary care services for the medically underserved. HRSA provides funding for training and technical assistance (TA) cooperative agreement recipients to assist grant applicants. GAO was asked to examine (1) to what extent medically underserved areas (MUA) lacked health center sites in 2006 and 2007 and (2) HRSA's oversight of training and TA cooperative agreement recipients' assistance to grant applicants and its provision of written feedback provided to unsuccessful applicants. To do this, GAO obtained and analyzed HRSA data, grant applications, and the written feedback provided to unsuccessful grant applicants and interviewed HRSA officials.

Grant awards for new health center sites in 2007 reduced the overall percentage of MUAs lacking a health center site from 47 percent in 2006 to 43 percent in 2007. In addition, GAO found wide geographic variation in the percentage of MUAs that lacked a health center site in both years. Most of the 2007 nationwide decline in the number of MUAs that lacked a site occurred in the South census region, in large part, because half of all awards made in 2007 for new health center sites were granted to the South census region. GAO also found that HRSA lacks readily available data on the services provided at individual health center sites. HRSA oversees training and TA cooperative agreement recipients, but its oversight is limited in key respects and it does not always provide clear feedback to unsuccessful grant applicants. HRSA oversees recipients using a number of methods, including regular communications, review of cooperative agreement applications, and comprehensive on-site reviews. However, the agency's oversight is limited because it lacks standardized performance measures to assess the performance of the cooperative agreement recipients and it is unlikely to meet its policy goal of conducting comprehensive on-site reviews of these recipients every 3 to 5 years. The lack of standardized performance measures limits HRSA's ability to effectively evaluate cooperative agreement recipients' activities that support the Health Center Program's goals with comparable measures. In addition, without timely comprehensive on-site reviews, HRSA does not have up-to-date comprehensive information on the performance of these recipients in supporting the Health Center Program. HRSA officials stated that they are in the process of developing standardized performance measures. Moreover, more than a third of the written feedback HRSA sent to unsuccessful Health Center Program grant applicants in fiscal years 2005 and 2007 contained unclear statements. The lack of clarity in this written feedback may undermine its usefulness rather than enhance the ability of applicants to successfully compete for grants in the future.

Status Legend:

More Info
  • Review Pending-GAO has not yet assessed implementation status.
  • Open-Actions to satisfy the intent of the recommendation have not been taken or are being planned, or actions that partially satisfy the intent of the recommendation have been taken.
  • Closed-implemented-Actions that satisfy the intent of the recommendation have been taken.
  • Closed-not implemented-While the intent of the recommendation has not been satisfied, time or circumstances have rendered the recommendation invalid.
    • Review Pending
    • Open
    • Closed - implemented
    • Closed - not implemented

    Recommendations for Executive Action

    Recommendation: To improve the Health Center Program, the Administrator of HRSA should reevaluate its policy of requiring comprehensive on-site reviews of Health Center Program training and TA cooperative agreement recipients every 3 to 5 years and consider targeting its available resources at comprehensive on-site reviews for cooperative agreement recipients that would benefit most from such oversight.

    Agency Affected: Department of Health and Human Services: Public Health Service: Health Resources and Services Administration

    Status: Open

    Comments: HRSA provided a detailed description of actions taken in response to this recommendation in it's FY2011 update. However, due to the lack of supporting evidence available to document these actions, this recommendation should remain open until such evidence is provided.

    Recommendation: To improve the Health Center Program, the Administrator of HRSA should develop and implement standardized performance measures for training and TA cooperative recipients that assist applicants to improve HRSA's ability to evaluate the performance of its training and TA cooperative agreements. These standardized performance measures should include a measure of the number of successful applicants a recipient assisted.

    Agency Affected: Department of Health and Human Services: Public Health Service: Health Resources and Services Administration

    Status: Closed - Implemented

    Comments: As part of our review of the Health Resources and Services Administration's (HRSA) oversight of assistance provided to health center grant applicants through training and technical assistance (TA) cooperative agreements, we found that the agency's oversight was limited because it lacked standardized performance measures to assess the performance of the cooperative agreement recipients. As a result, we recommended that the Administrator of HRSA develop and implement standardized performance measures to enhance its ability to assess the performance of its training and TA cooperative agreement recipients. Consistent with our recommendation, beginning in fiscal year 2009, HRSA included standardized performance measures for training and TA cooperative agreement recipients as part of its program guidance. Specifically, the guidance instructed cooperative agreement applicants to establish goals for three required performance measures as part of their application. The three required performance measures focused on health center satisfaction, program requirements, and performance improvement. HRSA has continued to require applicants to address specific performance measures in their applications. In fiscal year 2011, applicants were required to address four specific performance measures, including the same three goals from fiscal year 2009, and one additional measure that focused on program development/analysis. Developing and implementing standardized performance measures for training and TA cooperative agreement recipients improves HRSA's ability to assess recipients' performance and can help inform the agency in determining where to focus its limited resources.

    Recommendation: To improve the Health Center Program, the Administrator of HRSA should collect and maintain readily available data on the types of services provided at each health center site to improve the agency's ability to measure access to comprehensive primary care services in MUAs.

    Agency Affected: Department of Health and Human Services: Public Health Service: Health Resources and Services Administration

    Status: Open

    Comments: HRSA disagreed with recommendation, and in FY2011 response, continues to disagree.

    Recommendation: To improve the Health Center Program, the Administrator of HRSA should identify and take appropriate action to ensure that the discussion of an applicant's strengths and weaknesses in all summary statements is clear.

    Agency Affected: Department of Health and Human Services: Public Health Service: Health Resources and Services Administration

    Status: Open

    Comments: HRSA provided a detailed description of actions taken in response to this recommendation in it's FY2011 update. However, due to the lack of supporting evidence available to document these actions, this recommendation should remain open until such evidence is provided.

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