apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6)...

45
AD-A202 400 DIRECTORATE OF HEALTH CARE STUDIES AND CLINICAL INVESTIGATION APPLYING THE DEPARTMENT OF HEALTH AND HUMAN SERVICES UNDERSERVED AREA CRITERIA TO ARMY DENTAL FACILITIES James A. Lalumandler, LTC, DC Jay D. Shulman, COL DC DTIC MAR 311993D 00 January 1993 E DR993-001 i... ____ _ _ _ _=.• •• oIm proved fot public xeIeasq UNITED STATES ARMY MEDICAL DEPARTMENT CENTER AND SCHOOL FORT SAM HOUSTON, TEXAS 78234-6100 93-06554

Transcript of apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6)...

Page 1: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

AD-A202 400

DIRECTORATE OFHEALTH CARE STUDIES

AND CLINICAL INVESTIGATION

APPLYING THE DEPARTMENT OF HEALTH

AND HUMAN SERVICES UNDERSERVED AREACRITERIA TO ARMY DENTAL FACILITIES

James A. Lalumandler, LTC, DCJay D. Shulman, COL DC DTIC

MAR 311993D

00 January 1993 EDR993-001

i... ____ _ _ _ _=.• ••

oIm proved fot public xeIeasq

UNITED STATES ARMYMEDICAL DEPARTMENT CENTER AND SCHOOL

FORT SAM HOUSTON, TEXAS 78234-6100

93-06554

Page 2: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

f/\\

NOTICE

The findings in this report arenot to be construed as an official

Department of the Army positionunless so designated by other

authorized documents

Regular users of services of the Defense TechnicalInformation Center (Per DOD Instruction 5200.21 may purchascopies directly from the following:

Defense Technical Information Center (DTIC)ATTN: DTIC-DDRCameron StationAlexandria, VA 22304-6145

Telephones: DSN 284-7633, 4 or 5Commercial (703) 274-7633, 4 or 5

All other requests for these reports will be directed to thfollowing

U.S. Department of CommerceNational Technical Information Services (NTIS)5285 Port Royal RoadSpringfield, VA 22161

Telephone: COMMERCIAL (703) 487-4600

±

Page 3: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

Unclassified.;ECURITY CLASMIICATION, O-C 7=PA-

SForm Aobroved/

REPORT DOCUMENTATION PAGE OMBrNo 0704-0188

la. REPORT SECURITY CLASSIFICATION I0 RESTRICTIVE M0ARKING0

Unclassified2a. SECURITY CLASSIFICATION AUTHORITY' 3 DISTRIBUTION /AVAILABILITY OF REPORT

Distribution unlimited; Approved for public2o. DECLASSIFICATION/ DOWNGRADING SCHEDULE relec se.

A PERFORMING ORGANIZATION REPORT NUMBER(S) S MONITORING ORGANIZATION REPORT NUMBER(S)

DR 93-001

6a. NAME OF ,ERFORMING ORGANIZATION 6b. OFFICE SYMBOL 7&. NAME OF MONITORING ORGANIZATIONDirectorate of Health Care (If applicable) DA Office of the Surgeon GeneralStudies & Clinical Investigatio• HSHN-D,

6c. ADDRESS (City. State, and ZIPCode) 7b. ADDRESS (Ciry, State, and ZIP Code)ATTN: HShN-D (LTC Lalumandier) ATTN: DASG-DCGBldg 2268 Washington, D.C. 20310Fort Sam Houston, TX 78234-6100&a. NAME OF FUNDING/SPONSORING 8Bb. OFrICE SYMBOL 9. PROCUREMENT INSTRUMENT IDENTIFICATION NUMBER

ORGANIZATION (If applicable)I

8C. ADDRESS (City, State, and ZIP Code) 10. SOURCE OF FJNDING NUMBERSPROGRAM PROJECT TASK WORK UNITEL'EMENT NO. NO. NO. [ACCESSION NO.I I ?3A329022

'11. TITLE (InclSecure70*ithation) (U) Applying the Department of Health & Human Services

Underserved Area Criteria to Army Dental Facilities12. PERSONAL. AUTHOR(S

12. PERSOL ATR() LTC James A. Lalumandier & COL Jay D. Shulman

13s. TYPE OF REPORr 3b. TIME COVERED 14. DATE OF REPORT (Year, Month, Day) 1S. PAGE COUNTFinal FROMNoy 9 1TO Ta;n .3 1993 January 4116. SUPPLEMENTARY NOTATION

17. COSATI CODR.S 18. SUBJECT TERMS (Continue on reverse tf necessary and identify by block number)FIELD GROUP SUB-GROUP Active Army, Dental Care, Underserved Area Criteria,

19. ABSTRACT (Continue on revuise it necessary and identify by block number)

(U) At the request of the Chief, Army Dental Corps the Dental Studies Division of theHealth Care Studies and Clinical Investigation Activity (HCSCIA) plsnned and executed astudy to determine which DENTACs and standalo .a clinics are unierserved with respect tofamily member dental treatment.

To determine whether the Department of Health and Human Services' (DHHS) underservedcriteriacould be applied to Army dental facilities, a systematic approach was followed.Phase I required all DENTACs to provide their best estimates of their population tocivilian dentist ratio using 1974 dentist per county data and 1970 population data..Sixteen DEBTACs/clinics reported population to dentist ratios of at least 3,000 percivilian dentist. When 1990 census data and 1987 dentist per county data were appliedto the Phase I results 12 DENTACs/clinics were underserved by DHHS criteria.

20. OIS1RIBUTION/AVAILABILITY OF ABSTRACT 21. ABSTRACT SECURITY CLASSIFICATION13UNCLASSIFIED/JNLIMITED (3 SAME AS RPT ,, OTIC USERS Unclassified

22a. NAME OF RESPONSIBLE INDIVIDUAL 22b. TELEPHONE (Include Area Code) 22C. OFFICE SYMBOLLTC James A. Lalumandiei •(210) 221-0047 IHSHN-DDD Form ;473. JUN 86 Previous edmont are •bsolete. SECUP"rY CLASSIFICATION OF THIS P.APG

Unclassified

/i

Page 4: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

19. ABSTRACT (continued)

The DHHS underserved critetia can be applied to Army dental facilities tcassist in identifying dental manpower shortage areas. Also important is thedetermination and verification of the number of Delta Dental Plan providerswithin 35 miles of a family membcr's residence.

Accesion For

NTIS CRAMDTIC TABUr. ariouwnccd L]Ju-tificatdon

By.. .......................

Disttibjtion I

Availability Codes

Avail andlorDist I •.iecial

Page 5: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

TABLE OF CONTENTS

Page Number

DISCLAIMER........................ . .. ... . . .... .. .. .......

REPORT DOCUMENTATION PAGE (DD 1473) . . . . o.. .. . . .. .

TABLE OF FCONTNTTS .... .. ............................. iv

EXECUTIVE SUMMARY .. .. .. .. .. .. .... ... . . .vi

BACKGROUND .............. ... .. . . . . . 1

Access to Care ............................ ......... 1Shortage Area Designations .. .. .. ... . . . . 1Shortage Area Criteria. .................. ......... 2

DEPARTMENT OF HEALTH AND HUMAN SERVICES METHODOLOGY .... . . 3

UPDATED ME7.HODOLOGY ........ . .. .*. .. . .. 3

DEPENDENT DENTAL PLAN .................. 5

RECOMM4ENDATIONS. ......... ............. .. .. .. ..... 7

CONCLUSION . . . . .. .. .. ..... . . . . . . . . ... 8

REFERENCES . . . . . . . . . . . . . . . .. . . . . . . 9

Table 1: DENTACs/Clinic Reporting a Population ofat Least 3,000 per Civilian Dentist . . . . . . 13

Table 2: Census Population of at Least 3,000 perCivilian Dentist . .. .... ....... 14

Table 3: Population to Dentist Ratio Using 1990 Censusand 1987 Dentist Per County Data ............... 15

Table 4: Number of Participating Dentists andResidence of Family Members Reportedby Delta Dental Plan . .. .. .. .. ..... . . . 16

Table 5: DENTAC Verification of ParticipatingDelta Dentists and Residence of FamilyMembers . . . . . . . . . . . . . . . .. .. .... 17

iv

Page 6: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

-.7,. •

APPENDICES ........................................... 19

Appendix A:

Final Rule on the Criteria for HealthManpower Shortage Area Designations ......... 20(Federal Register, 17 Nov 1980, Vol. 45 No. 223)

Appendix B:

Reporting Form for Number and Specialtyof Each Practitioner, by County Within30 Miles of Post .... .............. . . . . . 31

v

- • . ... .. -.- _ .. ....... -\- - -- --

Page 7: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

EXECUTIVE SUMMARY

At the request of the Chief, Army Dental Corps the DentalStudies Division of the Health Care Studies and ClinicalInvestigation Activity (HCSCIA) planned and executed a study todetermine which DENTACs and standalone clinics are underservedwith respect to family member dental treatment.

To determine whether the Department of Health and HumanServices' (DHHS) underserved criteria could be applied to Armydental facilities, a systematic approach was followed. Phase Irequired all DENTACs to provide their best estimates of theirpopulation to civilian dentist ratio using 1974 dentist percounty data and 1970 population data. Sixteen DENTACs/clinicsreported population to dentist ratios of at least 3,000 percivilian dentist. When 1990 census data and 1987 dentist percounty data were applied to the Phase I results 12DENTACs/clinics were underserved by DHHS criteria.

The DHHS underserved criteria can be applied to Army dentalfacilities to assist in identifying dental manpower shortageareas. Also important is the determination and verification ofthe number of Delta Dental Plan providers within 35 miles of afamily member's residence.

vi

r/7

F... . -

/,

"*•-• -I. .. A . .~- * "

Page 8: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

vii

Page 9: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

Background

Access to Care

As resources allocated to family member dental care inHealth Services Command (HSC) decrease, civilian dental careunder the Dependent Dental Plan (DDP) will become an increasinglynecessary alternative. While there is little doubt that thereare sufficient dentists in metropolitan areas to supportincreasing family member enrollment in the DDP, Dental Activity(DENTAC) commanders in rural areas have expressed concern aboutthe ability of dentists in the surrounding communities to meetthe demand for care.

Shortage Area Designations

The earliest health manpower shortage area designations weremandated in 1965, by the Health Professions Education AssistanceAmendment (Public Law 89-290).1 This law provided for thecancellation of portions of outstanding Health ProfessionalStudent Loans obtained by dental students in return for theirservice after graduation in areas found to have shortages. TheAct also applied to students in schools of medicine, osteopathy,or optometry, and was based on county practitioner-populationratios. By 1971, the Comprehensive Health Manpower Training Act(Public Law 92-157)2 expanded to provide not only forcancellation of loans made by the government, but also forgovernment repayment of student loans incurred from othersources. It not only continued to make the Secretary of HEWresponsible for developing criteria for shortages but also foractually designating shortage areas. One year prior to the 1971Loan Repayment Act Congress passed the Emergency Health PersonnelAct (Public Law 91-623)3 creating a new unit, the NationalHealth Services Corps (NHSC) to provide health professionals toshortage areas. The first list of designated Critical HealthManpower Shortage Aias was assembled, and together with the

'United States Department of Health, Education, and Welfare.Health Professions Education Assistance ProQram: Report to thePresident and the ConQgress. Washington, D.C.: GovernmentPrinting Office, 1970.

2Cmprehensive Health Manpower Trainina Act of 1971.Statutes at Large. Public Law 92-157, Nov. 18, 1971. 92ndCongress: 85: 431-63.

3EmerQency Health Personnel Act of 1970, Statutes at Large.Vol 84, (1971).

i1

Page 10: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

shortage criteria was published in the Federai PRegister onOctober 23, 1974.4 By 1975, the (designation A ;ivity) wastransferred from NHSC to the Bureau of Health Manpower (BHM)within the Department of Health and Human Services (HHS). Arevision of the criteria for health manpower shortage areadesignations appeared in the Federal ReQister 5 by 1976. Thefinal rule was published in the Federal ReQister on November 17,1980 (Appendix A). 6

Shortage Area Criteria

The criteria for health manpower ireas are stated separatelyin the Federal Register for each of seven manpower types:(1) primary medical care manpower, (2) dental manpower, (3)psychiatric manpower, (4) vision care manpower, (5) podiatricmanpower, (6) pharmacy manpower, and (7) veterinary manpower.The basic criteria for the dental manpower are the geographicarea under consideratioii and the population to dentist ratio.For dental manpower, the area under consideration is determinedby a 40 minute drive. In mountainous terrain or in areas withonly secondary roads, a 40 minute drive translates into 20 miles.Under normal conditions with primary roads available thatdistance increases to 25 miles. In flat terrain, or in areasconnected by interstate highways, the driving distance is 30miles. Natural barriers such as rivers and/or mountains may alsoimpact on the distance one can travel in 40 minutes. The secondcriterion, can be determined by dividing the population by thenumber of full-time equivalent (FTE) private practitioners. Thepopulation is determined from the total permanent residentcivilian population of the area, using census data. Adjustmentsto that population for seasonal residents and/or migratoryworkers may be included using a weighing scheme. The number ofdental practitioners is determined by counting all non-federaldentists providing patient care. Where appropriate data areavailable, full-time equivalent dentist counts are used byutilizing age of dentist or hours spent in the dental practice.

4Department of Health, Education, and Welfare. PublicHealth Service, Federal Register, vol 39, no. 206 (23 October1974).

5RC Lee, "Designation of health manpower shortage areas foruse by Public Health Service programs," Public Health Rep Vol.94, (1979 Jan-Feb): 48-59.

'Health manpower shortage areas. Criteria for designationof areas having shortages of dental manpower. Federal ReQistervol 45, no. 23: 76003-5 (17 Nov 1980).

2

Page 11: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

Department of Health and Human Services Methodology

The methodology was developed in November 1977 and publishedin a report entitled "Report on Development of Criteria forDesignation of Health Manpower Shortage Areas". 7 Department ofHealth and Human Services (DHHS) first cal'-ulated the populationper dentist per county throughout the United States. Populationfigures per county were derived from 1974 Bureau of Censusestimates. The number of licensed dentists in each county wascalculated using 1974 data then adjusted using age-specificproductivity data obtained from a national survey of licenseddenti;ts, carried out in 1969-1970. The population per dentistratios by county were then rank-ordered. The median populationto dentist ratio was 3,239:1. An approximate median wasdetermined to be 3,000:1, and was chosen to indicate an adequatelevel of dental care, 150% of the median was 4,258:1 and theanalysis of this ranking showed that the lowest quartile was5,159:1. The value of 5,000:1 was chosen to indicate shortage,on the basis of the above values for 150% of the median and thelowest quartile.

The area for the delivery of dental care was determined tobe a 40 minute commute from the population center. According toa study, "Public Acceptance of Prepaid Group Practices",completed at the University of Michigan in 1967, 92% of alldental patients travel less than 40 minutes (one-way) to thedentist. Since the study indicated that most dental care iscarried out on an advance appointment basis rather than on theimmediate or next-day basis, DHHS used a 40 minute travel time.Although DHHS used 150% of the median ratio to indicate physicianand dentist shortage, the travel time to a physician's office wasreduced to 30 minutes because the time and distance to aphysician:s office was presumed to be more of a factor formedical care than dental care.

Updated Methodology

In developing updated criteria it was important to beconservative when computing travel time for dental care whileupdating the population to dentist ratio. Using DHHS criteriathe largest geographic area included a 30 mile radius from thepopulation center of post. Only natural barriers, such as riversor mountains, precluded using a 30 mile radius. Looking at thesecond criterion, i.e., population dentist ratio, DHIIS ised data

7Bureau of Health Manpower. (1977). Report on developmentof criteria for desianation of health manpower shortage areas(BHM/OPD/MAB, Report No. 78-03). Hyattsville, MD: Department ofHealth and Welfare.

3

Page 12: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

that was apprcý ately 20 years old. In order to update theratio, 1987/ic ýata represented the most current figures forpopulation per uuntist, we were able to collect data only at thestate level. The statewide population per dentist ratios wererank-ordered to determine the new median population to dentistratio, i.e., 1,920;1. Since DHHS determined that 150% of themedian indicated shortage area, the new shortage ratio wascalculated to be 2,880:1. We conservatively set the cut-offpoint at 3,000:1. A DENTAC or free-standing Army dental clinicwould only be considered potentially underserved when its ratioof population to dentist was at least 3,000:1. In order to focuson the DENTACs and free-standing clinics that were underserved,we made first-order approximation of the population and number ofcivilian dentists within 30 miles of each post using dataprovided by the DENTACs. This first stage resulted in 16DENTACs/Clinics reporting a population of at least 3,000 percivilian practitioner (Table 1).

Next, we applied a more precise population to dentist ratioto the 16 DENTACs/Clinics that remained in the analysis. TheBureau of Census was able to provide exact 1990 populationfigures for a 30 mile radius of map coordinates. Using thecoordinates of the center of population on post, the totalpopulation of the area was captured along with a populationbreakdown per county. The Regional Census Offices were able togive county populaticns for states within their region. Weacquired the most recent county-level dentist reports (1987/1988)for each county within the circumscribed areas from the Bureau ofEconomics and Behavioral Research, American Dental Association.For each county the number of FTEs was calculated as follows:each private practitioner working 30 hours or more was counted as1 FTE while a practitioner working less than 30 hours was countedas .75 FTEs. Full-time equivalent calculations were accuratelynoted for counties completely within the 30 mile radius. Forcounties partially within the circle it was assumed that dentistswould be distributed according to population. By calculating theproportion of people living in the county within the circle, anequivalent proportion of FTEs was assumed to be practicing withinthat portion of the counýty. The total FTEs were then summed foreach circumscribed area.' The population to dentist ratio ofPhase II was calculated by dividing total area population minusactive duty soldiers by the total FTEs within 30 miles of post.From this second step the only estimation was the number ofactive private practitioners within the circumscribed area.Nonetheless we had narrow d the potential shortage areas to 12(Table 2).

Although the DENTAC t West Point was far below the shortagecriteria, the Hudson Rive, and Catskill Mountains, impacted onthe distance one can drive in 40 minutes. Phase III required the

4

Page 13: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

12 DENTACs/Clinics plus Fort Huachucal to make a very thoroughsearch of their circumscribed areas noting the number of privatepractitioners and their specialties. A form was provided to eachof the 12 DENTACs/Clinics to fill out indicating the number andspecialty of each practitioner by county within 30 miles of thepost (Appendix B). Due to the natural barriers around WestPoint, the West Point OENTAC commander elected to determine thearea for the delivery of dental care by a 40 minute travel timefrom post. After he had determined the geographic area, HealthCare Studies and Clinical Investigation Activity (HCSCIA) usedcensus tract maps of 1990 census data and determined the exactpopulation of the area. The New York Regional Census Officeprovided population figures per tract to make calculations asaccurate as possible.

Phase TII resulted in the most accurate ratio of populationper dentist (Table 3). By subtracting out the active dutysoldiers from the total population the resultant numberrepresented potential patients for the private practitionerswithin 30 miles of post. The number of dentists were the activeprivate practitioners in private practice within 30 miles ofpost. Without a dental insurance plan for family members ofactive duty soldiers, Table 3 would have represented the bestguide for determining which DENTAC and/or clinic should be deemedunderserved.

Dependent Dental Plan

The present Delta' contract runs through 31 July 1995.Delta is responsible for developing and maintaining participatingdentistl° who are able to provide dental services tobeneficiaries, i.e., active duty family members. The beneficiarymust be able to access care for a routine appointment within 21calendar days from a participating provider whose office iswithin 35 miles of the family member's residence. If

'Fort Huachuca, Arizona, had undercounted their surroundingpopulation in Phase I.

'Delta is the name of the program which administers theDependent Dental Plan for the Office of Civilian Health andMedical Program of the Uniformed Services.

`Participating dentists are paid by Delta Dental less anycost share. Payment for services is based upon the dentist'susual fees notwithstanding Delta's customary charge. Forpreventive services, e.g., dir~nostic, emergency palliative, orprophylaxiL, there is no cost sharing by the beneficiary. Forrestorative services the cost share is 20% to be paid by thebeneficiary.

5

Page 14: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

those two conditions cannot be met, Delta is ,'bliged to pay theusual fee, less the 20% cost share" for restorative services,or any nonparticipating provider located within 35 miles of thebeneficiary's residence.

N~onparticipating providers are dentists who have not signedon with Delta. Payment for services to this category ofprovider is usually determined by Delta at a level not less thanthe 50th percentile of the prevailing fen~s (or at the actualcharge if lower) with any remaining amount paid by thebeneficiary. These dentists are either nonparticipatingproviders accepting assignment or nonparticipating providers whopractice in states that do not allow assignments of benefits.The states that permit nonparticipating providers to be paiddirectly by insurance companies (accepting assignment) areAlaska, Alabama, Georgia, Indiana, Louisiana, Montana, Nevada,Texas, Utah, and Washington. State law in the remaining statesprohibits nonparticipating providers from being paid directly byinsurance companies. In these cases the beneficiary is paid byDelta and the nonparticipating provider bills the farily member.

Although research has shown that over 90% of all dentalpatients travel less than 40 minutes (30 mile one-way) to thedentist, the contract was negotiated for a diatance of 35 milesfrom the beneficiary's residence. Sierra Army Depot, DugwayProving Ground, White Sands Missile Range, and Yuma ProvingGround, are located on a post where the majority of active dutyfamily members reside in post quarters. Therefore, for thosefour clinics a listing of Delta participating dentists wasrequested within a 35 mile radius of the post. Fort Stewart,Fort Bliss, Fort Benning, Fort Huachuca, Fort Bragg, and FortSill, are located on major installations where the majority offamily members either live on post or within five minutes ofpost. For those DENTACs a listing of participating Deltadentists was requested within 40 miles of post. Only Fort Irwinand Fort Polk have any sizeable number of family members livingfurther than 5 miles from post. Family members whose sponsor isstationed at Fort Irwin either reside on post or in Barstow, CA,37 miles from post. There is no practicing civilian dentistwithin 35 miles of Fort Irwin. A list of Delta participatingdentists was requested within 35 miles of Barstow. At Fort Polk,LA the majority of family members either live on post or in twocommunities: Leesville ten miles north of post or Deriddertwenty miles south of post. For 'Fort Polk three separate listsof Delta participating dentist were requested for each locationat a radius of 35 miles.

"Cost share is the amount of money (co-payment) which the

family member (or sponsor) is responsible to pay.

Page 15: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

The various lists of participating dentists were requestedfrom the Delta Manager of Program Relation and EnrollmentService. Table 4 shows not only where family members reside butalso the number of Participating Dentists within 35 miles oftheir residence. These lists were then sent to DENTAC commandersand clinic officers-in-charge for verification. Discrepancies inthe lists were found. Providers were double counted, specialistsother than pediatric dentists were counted, providers who hadrelocated, retired or were no longer accepting Delta patientswere counted. Table 5 shows the twelve DENTACs/clinics with themost accurate number of Participating Dentists.

As can be seen there are major discrepancies between thelists of Participating Dentists provided by Delta and the actualnumber of participating dentists. For example, of the 25 Deltaproviders within 35 miles of Fort Polk only 6 general orpediatric dentists had signed on with Delta. Furthermore, allproviders were unable to provide a routine appointment within 21calendar days of the DENTAC's call. Also complicating thesituation is the fact that very few dentists have establishedpractices within 35 miles of Fort Polk. After reviewing thesituation at Fort Polk, Delta acknowledged that there was aproblem providing dental services to family members living onFort Polk.

Table 5 shows that family members living on Fort Irwin andFort Polk do not have adequate access to dental care as providedby Delta Dental. By checking on availability of routineappointments, DENTACs/clinics other than Fort Polk may discoverinadequate access to care.

Recommendations

1. Delta Dental should update and verify their lists ofparticipating dentists at least once a year, preferably every sixmonths.

2. The list of dentists needs to indicate whether thedentist is a gereral practitioner or a specialist.

3. The list of providers should only include thosedentists within the 35 miles radius of the beneficiary'sresidence.

4. The contract should call for a maximum 40 minute driveof 30 miles from the beneficiary's residence.

5. A toll-free telephone number should be made availableto beneficiaries for reporting access problems.

7

Page 16: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

Conclusion

The DHHS criteria for determining dental manpower shortageareas can be applied to the Army Dental Care System. Theirunderserved criteria has provided a basis to determine whichposts could justify treating family members and counting theworkload.

/I

Page 17: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

References

Bureau of Health Manpower. (1977). Criteria for Designation ofHealth Manpower Shortage Areas. BHM/OPD/M•B. (Report No.78-03). Hyattsville, MD: Department of Health and Welfare.

Comprehensive Health Manpower Training Act of 1971.ý UnitedStates Statutes at LarQe. Vol 85, 431-463.

Emergency Health Personnel Act of 1970. United States Statutesat LarQe. Vol 84, Part 2, 1868-1871.

Lee, Richard C. (1979). Designation of Health Manpower ShortageAreas for Use by Public Health Service Programs. PublicHealth Reports, 94, 48-59.

US Department of Health and Human Services. Health Resourcesand Services Administration. List of Designated DentalHealth Manpower Shortage Areas (Dental HMSAs); List ofWithdrawals From Dental HMSA Designation; Notice. FederalRegister (8 January 1986) Vol. 51, No. 5.

US Department ol Health and Human Services. Public HealthService. Criteria for Designation of Health ManpowerShortage Areas; Final Rule. Federal Register (17 November1980) Vol. 45, No. 223.

US Department of Health, Education, and Welfare. HealthProfessions Education Assistance Program: Report to thePresident and the Congress (1970). Washington, DC:Government Printing Office.

US Department of Health, Education, and Welfare. Public HealthService. Critical Health Manpower Shortage Areas. FederalReaister (23 October 1974) Vol. 39, No. 206.

US Department of Health, Education, and Welfare. Public HealthService. Proceedings of the Workshop on Health ManpowerShortage Areas. (8-10 November 1976).

9

Page 18: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

10

Page 19: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

TABLES

Page 20: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

12

Page 21: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

TABLE I

DENTACs/Clinics Reporting a Population of at Least 3,000 perCivilian Dentist

DENTAC DENTAL CLINICS

Fort Benning Dugway Proving Ground

Fort Bliss Fort ChaffeeSFort Bragg Pine Bluff Arsenal

Fort Irwin Sierra Army Depot

Fort Leavenworth Stewart Army Airfield

Fort Polk White Sands Missile Range

Fort Sill Yuma Proving Ground

Fort Stewart

West Point

13

- _--2 ._. _ _, / -'-

Page 22: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

TABLE 2

Census Population of at Least 3,000 per Civilian Dentist

DENTAC DENTAL CLINICS

Fort Benning Dugway Proving Ground

Fort Bliss Pine Bluff Arsenal

Fort Bragg Sierra Army Depot

Fort Irwin White Sands Missile Range

Fort Polk Yuma Proving Ground

Fort Sill

Fort Stewart

14

Page 23: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

Table 3

Pop.lation To Dentist Ratio Using 1990 Census and 1987 DentistPer County Data

DENTACS/CLINICS Phase IIIPopulation toDentist Ratio

Sierra Army Depota 17,092:0

Fort Irwina 9,717:0Dugway Proving Ground'b 5,496:0

Fort Polk&" 6,555:1

Fort Stewartab1 6,419:1

White Sands Missile Range' 5,327:1

Fort Blissk 4,333:1

Yuma Proving Groundb 4,145:1

Fort Benninge 3,985:1

Fort Huachucal 3,829:1

Fort Bragge 3,286:1

Fort Sill 2,935:1

Pine Bluff Arsenal 2,695:1

West Point 1,560:1

Note: Old Median = 3,239:1New Median = 1,920:1

S Underserved as defined by DHHS (5,000:1)

S•- Underserved using 200% of new median (3,840:1)

Underserved using 150% of new median (2,880:1)

. 15

# v- -

Page 24: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

co RP w N 0 il n o cc

"C1 C4 qv - 4 en N n en r-LUf in c N 0 n qv r. % O

-0% ;4 1: %; 0; 0%N N C4 N-

at C4 in c

C1 c N V44

co urn 4 nV4C

.4 P4

U.LL

Page 25: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

0 C4V 0 04 atn m 0 %n in

in 0 1 - '0 en 0% cc

'4 N C4 N .4 - N

40 q

a9' in1 a%-c

.4 1.N % en C

in' in q 0 ' fn

N4 g40 - M 0

010".4

'0 0 0I

in N N wN '1! 0%

Page 26: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

18

Page 27: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

APPENDICES

19

I -

-

Page 28: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

20

Page 29: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

APPENDIX A

Final Rule on the Criteria for Health Manpower ShortageArea Designations (Federal Register, 17 Nov 1980,

Vol. 45, No. 223)

I

21

/1

i• ' " / \ \ ,- /. •.... . " /

" """ / / ,• •

Page 30: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

22

A /A'

/

/1 - A' / - - - I -�7'

7 / --- - - -. .',

Page 31: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

- MondayNovember 17, 1980

Part IV

Department ofHealth and HumanServicesPuablic Health Service

Criteria for Designation of HealthManpower Shortage Areas; Final Rule

Page 32: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

76000 Federal Register ' Vol. 45, No. 223 I Monday. November 17. 1980 I Rules and Regulations

be a significant consideration In bem designated by the Secretary. under to the Department. Relevant portions ofdetermining relative priorities for NHSC section 1511 of the Act. for purposes of this material will then be forwarded topersonnel. or for other PHS programs, health planning activities, each health systems agency, State

Various changes of an editorial or "Health systems agency" or "lISA" health planning and developmenttechnical nature have also been made to means the health systems agency agency, and Governor. who will beclarify the regulations. designatecL under section 1515 of the asked to review the listings for their

Accordingly. Part 5 of 42 CFR is Act. to carry out health planning State. correct any errors of which theyrevised as set forth below, activities for a specific health service are aware, and offer their

Do"- Septemhber 3. 19f area. recommendations. if any, within goJulius &. Richmid. "Medical facility" means a facility for days. as to which geographic areas.Asaiatnt Seaay for Helth. the delivery of health services and population groups. and facilities in areas

SA 0.nCtf ober, S . Includes: (1) A community health center, under their jurisdiction should bePapria R toberts H s. public health center, outpatient medical designated. An information copy of

habida ItobertS K , facility, or community mental health these listings will also be made,ecrag. center. (2) a hospital. State mental available, upon request. to interestedPART S-DESIGNATION OF KEALTH hospital. facility for long-term care. or parties for their use in providingSSehabilitation facility; (3) a migrant comments or recommendations to theMANPOWER SHORTAGE AREAS health center or an Indian Health Secretary and/or to the appropriateIS.s service facility*. (4) a facility for delivery HSA. SHPDA. or Governor.5.2 Purpose. of health services to inmates in a US. (b) In addition, any agency or5U Definitions, penal or correctional institution (under Individual may request the Secretary to"5.3 Procedure for designation of health section 323 of the Act) or a State designate (or withdraw the designation

manpower shortage areas. correctional institution; (5) a Public of) a particular geographic area.1.4 rotification and publication o Health Service medical facility (used in population group. or far"Ity as a health

deAppenixns and Cr toDsiwalt connection with the delivery of health manpower shortage area. Each requestAppendix A. CrStha for Deslofuimoa r services under section 320. 321. 3=.'324. will be forwarded by the Secretary toArea havig Shrae of Primary

Medical Caem Mnpower. 325. or 325 of the Act). or (6) any other the appropriate HSi,. SHPDA. andAppendix B. Criteria for Designation of Areas Federal medical facility. Governor. who will be asked to review

having Shortages of Dental Manpower. "Metropolitan area" means an area It'and offer their recommendations, ifAppendix C. Critena for Designation of which has been designated by the Office any. within 30 days. An information

Areas having Shoreges of Psychiatric of Management and Budget as a copy will also be made available tof anpowor. . standard metropolitan statistical area other Interested parties, upon request,Appedix 0. Criteria for De'sinsution ofArese havin Shortae s of Vision Care (SMSA). All other areas are "non- for their use In providing comments or

M angpower metropolitan areas." recommendations to the Secretary and/

Appendix . Criteria for Designation v A "Poverty level" means the povery or to the appropriate HSA. SHPDA. orhaving Shortage, of Podiatric Manpower. level as defined by the Bureau of the Governor.

Appendix F. Criteria for Designation of An"as Census. using the poverty Index adopted (c) In each case where the designationhaving Shcrtages of Pharmacy by a Federal Interagency Committee in of a public facility (including a FederalManpower. 19. and updated each year to reflect medical facility) is under consideration.

Appendix G. Criteria for Designation in changes in the Consumer Price Index. the Secretary will give written notice ofAreas hvg Shortages of Veter-uar "Secretary" means the Secretary of the proposed designation to the chiefmanpower. Health and Human Services and any administrative officer of the facility. -

AathaSeAt Sec•to .15 of the PUbiU c Health other officer or employee of the who " be asked to review it and offerServic Act, 55 Stat. N0 42 U.S.C. 21S)Section 332 of the Public tisath Sevic Act. Department to whom the authority their recommendations, if any, within 3050 StaL 2770.=2Z (42 U.S.C. Zss*. Involved has been delegated. days.

"State" includes, In addition to the (d) After review of the available.5.1 Pwpoes. several States, the District of Columbia. Information and consideration of the

These regulations establish criteria the Commonwealth of Puerto Rico. the comments and recommendationsand procedures for the designation of Northern Mariana Islands, the Virgin submitted. the Secretary will designategeographic areas, population groups. Islands. Guam. American Samoa. and health manpower shortage areas andmedical facilities, and other public the Trust Territory of the Pacific Islands. withdraw the designation of any areasfocilities. In the States. as health "State health planning and *which have been determined no longermanpower shortage areas. development agency" or "SHIPDA" to have a shortage of health manpower.I b Dofbwoom means a State health planning end"development agency designated under * sd NtIf and piubl of

"Act" means the Public Health secton 152= of the Act, ntiof sli wAthdawa.Service Act, as amended. , (a) The Secretary will give written

"Health manpower shortage area" I 3 Poede for dSIf4faori of laieli notice of the designation (or withdrawalmeans any of the foUowi~g which the Mao" -0 1111ý aeas. of designation) of a health manpowerSecretary determines has a shortage of (a) Using data avaflable to the shortage ares, not later than 50 dayshealth manpower. (1) An urban or rural Department from national. State. and from the date of the designation (orarea (which need not conform to the local sources and based upon the withdrawal of desegnation), to:geographic boundaries of a political criteria in the Appendices to this part. (1) The Governor of each State Insubdiviion and which is a rational area the Department will annually prepare which the ars.a, population group.for the delivery of hetlth services) (2) a listings (by State and health service medical facility, or other public facilitypopulation group; or (3) a public or area) of currently designated health so designated is in whole or in partnonprofit private medical facility, manpower shortage areas and located.

"Health service area" means a health potentially designatable areas, together (2) Each HSA for a health service areaservice area whose boundaries have with appropriate related data available which includes all or any part of the

'A,

Page 33: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

rFederal Regoster jVol. 45. 5,No. 223 /Monday, November 17. 1980 Rules and Regulations 76001

an&a. population group, medical facility., 3 Methodology.ditnecorsnigto3mnusorother public facli~ty so designated; in determining whether an area moets travel time:

(3) T~he SIIA for each State in the criteria established by paragraph A (i) Under normal conditions with

which the are&. population group. of this part. the following methodology primary roads available: 2D mike..

medical facility, or other public facility will be used:- (Hi) In mountainous terrain or in areas

so designated is in whole or in part 1. Rational Arras for the Deli vely of with only secondary roads available: 15

located;- end hrima MediFcal Corm Services. moles.

(4) Appropriate public or nonprofit ()Teflwigareas will be M Iln fet tarrl~i atin areas

private entities which ar located in or consideW'reda~tioa areas for the connected by interstate high ways: 25

which have a demonstrated Interest in deli very of primary medical care miles.

the area so dsgae.services: Within inner portions of metropolitan

db n estigntd wil dcally (i) A county. at a poup of contiguous areas. information on the public

C lThupaed lit frsga counties whose population centers are transportation system will be used to

plish uapdated lshotag of reasinthed within 30 minutes travel time of each determine the distance corresponding to

hedealth gser ytyeo manpowershraeia other. 20 minutes trevel time.

sedertalgser, by udtpedls of manpsowr (U)l A portion of a county, or an area 2.Population CounL

eahrtype oanupdotedlshotfage willob made upof portion&sof more than one 710epopulation countused wllbe te

eaclihe atypeaof manpoe shrannu wlly be county. whose population. because of total permanent resident civilian

Spulihed afetiv leastoce annuathy topography, market or transportationi population of the area,. ewxcilhuding

(c) Te effctiv dateof ~patternts ditinctive population inmates of institutionswtth

digatin of an area shall be the date characteristics or other factors has following adjustments. where

of the notification lttter to the Individual limited access to contiguous area appropOriae

or agency which requested the resources. as measured generally by a (a) Adjustments to the population for

designation. or the date of publication In travel time greater than 30 minutes to the differing health service requirements

the Federal Register. whichever comes srch resources. of various ag"sx population groups

fint. (Wil Established neighborhoods and will be computed using the table below

(d) Once an area is listed in the et communities within metropolitan areas of visit rates for 11 age-sex population

lFederal Register as a designated heat which display a strong self-identity (is cohorts. The total expected visit rate

manpower shortage area. the effective indicated by a hon'ogenet.. will first be obtained by multiplying

datea' ofsianyatern wihdawal betedt socioeconomic cr demorme,%l, structure each of the 12 visit rates In the table by

areas desifination shllb the wtdratelo and/or a tradition of interaction or the size of the area population within

whn notpdatid on of deinthed wiareawso interdependency). have limited that particular age-sex cohort and

anichpdatedlst nof inldesIgnted ares pbihd Interaction with contiguous areas. and adding the resultant 12 visit figures

whih des ot nclde t. s pbbaed which. in general, have a minimum together. T`his total expected visit rate

In the Federal Registe. noulation of 20.000. will then be divided by the U.S. average

Appendix A-Criteria for Desigation of POX)The following distances will be per capita visit rate of 5.. to obtain the

Ameas Having Shortages of Primary ussed as guidelines in detenninlng adjusted population for the area.

Medical Can Manpower

A. Cditarlb. JW6 64 40 nM 44 01&a

A geogrsphic area will be designated _________ is Is 9. S 4.? G.A

as having a shortage of primary medical GA GA. a9 a as Go

care manpower if the following threecriteria are met: (b) The effect of transient populations populatiao. using the following formula:

2.-The area is a rational mra forth. on the need of an area for primary care Effective migrant contribution to

daiely of primary medival cam manpower will be taken intos ac oun a population=..Ifraction of year migrants

srie.follows: are present in mra) x (average daily

2. one of the following conditions pi) seasonal residents. Lte. those who number of migrants during portion of

prevals5 within the ma.e:_ maintain a residence in the area but year that migrants an present)-

(a) The ama has a population to ful Inhabit it for only 2 tog8 months per year. &. Counting of Primary Core

time-equivalent primary care physician may be included but must be weighted Pnrtitoners-

ratio of at least 3.100:1 LIn proportion to the fraction of the yewr (a) All non-Federal doctors of

(h) Th aema has a population to full they armproasent in the ma. medicine (MMD.) and doctors of

time.uIvalent primatry cam physician (Ui) Othier tourists (non-residtnt) may osteopathy (D.O.) providing direct

ratio of less than 2.50:1I but greater be included in an area's population hut patient care who practice principally In

than &M0:1I and has unusually high only with oaweight of 0OIL using the one of the tour primary care

aeeds for primary cewe services or following formula: Effective tourist specialilte- general or family practice.

insufficient capacity of existing primary contributiointo populaticaon.02x(froo- general interna medicine, pediatrics.

cam providers. tion of your uRsistare present in and obstetrics and gynecology-wlll be

L Primar? medical care manpower to me) x (average dally number of tourists counted. Those physicians engaged

contiguous marea mn overutillsed. during -odo of year that tourists in solely in administrationt. research. and

excessively distant. or Inaccessible to pre 1n). teacin will be excluded. Adjustments

the popuation of the area under (il irtory workers and thir forthe floIn fcors will be made in

eon~ldtiom.families may be included In an are's

Page 34: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

73002 Federal Register / Vol. 45, No. 23 / Monday. November 17. 1980 / Rules and Regulations

computing the number of full-time- 4. Determination of Unusually Hish population of the area under

equivalent (FTE) primary cam Netd&for himol Medici Carm consideration because of specifiedphysicians: Service. access barriers, such as:

(ey Interns and residents will be An ares will be considered as having (i) Significant differences between thecounted a n 0.1 full-time equivalent will E) unusually high needs for primary health demographic (or socioeconomic)

physicians, care services if at least one of the characterittics of the area under

() a s of foreign medical following criteria is me: consideration and those of the(U) hraduatm not citie ordiael (a) The ares has more than 100 births. contiguous area, indicating that the

schools who are not citizens at lawful per year per 1.000 womer. aged 15-44. population of the area underpermanent residents of the United (b) The area has more than 2D infant consideration may be effectivelyStates will be excluded from physician deaths per 1.000 live births. isolated from norby resources. Thiscounts. (c) More than 20% of the population isolation could be alidicated. for

(teW) Those graduates of foreign (or of all households) have incomes example, by an unusually high.medical schools who are citizens or below the poverty level proportion of non-English-speakinglawful permanent residents of the L Determination of nwufficient persons.United States. but do not have Capacity of E&xsW Primary Carp (U) A lack of economic access tounrestricted licenses to practice Providers, contiguous area resources. as indicatedmedicine, will be counted as 0.5 FTE An area's existing primary c particldarly where a very highphysicians. providers will be considered to have proportion of the population of the aeam

(b) Practitioners who are semi-retired. insufficient capacity if at least two of under consideration is poor (i.e.. wherewho operate a reduced practice due to the followino criteria are met: more than 20 percent of the populationinfirmity or other limiting conditions, or (a) More than 8.000 office or ur the households have incomes belowwho provide patient car services to the outpatient visits per year per FTE the poverty level). and Medicaid-

residents of the area only on a part-time primary care physician serving the ares covered or public primary care servicesbasis will be discounted through the use (b) Unusually long waits for are not avalable in the contiuout area.of full-time equivalency fipures. A 40- appointments fcr routine medical r- Determination of Denree onhour work week will be used as the services (I.e.. more than 7 days for short".standard for determining full-time established patients and 14 days for Designated areas will be assigned to

equivalents in these cases. For new patients). degree-of-shortage groups. based on theprctitioners working less than ad4- (c) Excessive average waiting time at ratio (R) of population to number of full-

week. every four (4) hours (or % primary care providers (lSnger than one time equivalent primary care physiciansday) spent providing patient care, in hour where patients have appointments and the presence or absence ofeither ambulatory or inpatient settings, or two hours where patients are treated unusually high needs for primary health

- -will be counted as 0.1 FM (with on a first-come, first-served basis). care services. according to the following* numbers obtained for FTE's rounded to (d) Evidence of excessive use of table:

the nearest 0.1 FTE), and each physician emergency room facilities for routine

"prcmviding patient care 40 or more hours primary care. _i_

a week will be counted as 1.0 FTE (e) A substantial proportion (2/3 orphysician. (For cases where data am more) of the area's physicians do not a" I N 4 L NP 0

available only for the number of hours accept new patients. ^&LOW

providing patient care in office settings, (f) Abnormally low utilization of ... sm fsm

equivalencies will be provided in health services, as indicated by an ,,, 3, -

guidelines.) "average of 2.0 or less office visits per(u) In some cases, physicians located year on the part of the area's population.

within n soe may not be accessible to a Contiotous Amea Considerations. Part li-.Population GroupsPrimary care manpower in areas

the population of the area under contiguous to an area being considered A. ailtUiO.consideration. Allowances for for designation will be considered 1. In general. specific populationphysicians with restricted practices can excessively distant. overutiilzed or groups within particular geographicbe made. on a case-by-case basis. Inaccessible to the population of the areas will be designated as having aHowever. where only a portion of the area under consideration if one of the shortage of primary medical care

population of the area cannot access following conditions prevails in each manpower if the following three criteriaexisting primary care resource outiguos area: are metiarea, a population group designation (a) Primary care manpower in the (a) The area In which they reside ismay be more appropriate (s" Part i of contiguous area are more than 30 rational for the delivery of primarythis Appendix). minutes travel time from the population medical care services, as defined in

(d) Hospital staff physicians Involved center(s) of the area being considered paragraph 1.1 of Part I of this Appendix.exclusively in Inpatient care will be fo' designation (measured in accordance (b) Access barriers prevent theexcluded. The number of full-time with paragraph B.1(b) of this Part). population group from use of the area's

equivalent physicians practicing in (b) The contiguous area population-to- primary medical care providers. Such

organized outpatient departments and full-time.equivalent primary cam barriers may be economic. linguistic."primary care clinics will be included. physician ratio is in excess of 20:.L cultural. or chitecturaL or couldbut those in emergency rooms will be indicating thai practitioners in the involve refusal of some pioviders toexcluded. contiguous area cannot be expected to accept certain types of patients or to

(e) Physicians who ar suspended help allevate the shortage situation in accept Medicaid reimbursemenL

under provisions of the Medicare- the area being considered for (c) The ratio of the number of persons

Medicaid Anti-Fraud and Abuse Act for designation. In the population group to the number of

a period of eighteen months or more will (c) Primary care manpower in the primary care physicians practicing in

be excluded. contiguous area are inaccessible to the

-- i- - / '

Page 35: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

Federal Regster IVol. 45. No. 223 /Monday. November 17. 1980 IRules and Regulations 76003

the area and sarving the population Group 2-Other histit utions with so (ii) There is excessive usage ofgroup is at least 3.0%1:1. physicians and institutions with R>L2OOO. emergency room facilities for routine

2. "*ndon and Alaska Natives will be Group 3-4nsttutions with LO0o>R)01=Oo prmr canconsidered for designation as having 3. Public or Non-Profit Medical? (liii) Waiting time for appointments isesbartagen of primary care manpower as Facilities, more than 7 days for establishedfollows: I. Cnteria. patients or more than 14 days for new

(a) Groups of members of Indian Public or non-profit private medical patients. for routine health services.tribes (as defined in section 4(d) of Pub. facilities will be designated as having a (lv) Waiting time at the facility isL 9"437. the Indian Health Care shortage of ;rimary medical came longer than 1 hour where pa jents hcveImprovement Act of 1970) are manpower if: appointments or 2 hours where patientsautomatically designated. (a) the facility is providing primary are trea ted on a first-comie, first-served

(b) Other groups of Indians or Alaska medical care services to an area or basis.Netiv~a (as defined in section 4(c) of population group designated as having a 3. Determinaintion of Degree ofP&b L 96437) will be designated If the primary care manpower shortage: and Shortage.general criteria in paragraph A are met. (b) the facility has insufficient Each designated medical facility will

IL Deteruination of Degree of capacity to meet the primary ca ned be assigned to the same degree-of-Shortage, of that area or population group. shortage group as the designated ares or

Each designated population group willl L. Methodology population group which it serves.be assigned to a degret-of-ahortage In determainin whether public or Appendix S--Cliteria for Designation ofgroup, based on the ratio (R) of the nonprofit private medical facilities meet- Areas Having Shortages of Dentalgroup's population to the number of the criteria established by paragraph 1.1 Manpowerprimary care physicians serving it. as of thi Part, the following methodology I- rphiAeafollows: will be used.PatAGorpiAesGroup I-No physicians or Pae Loa00 (a) Provision of Services tooa A. Criteria.GrOup -6.000>0S4.000. Designated Anea or Population Groiup. A geographic area will be designatedGroup 3-4.1300>R~aUMOO *4facility will be considered to be as having a dental manpower shortage ifGroup 4-w>R3 prn iding services to a designated area the following three criteria are met:

Population groups which have or population group if either. L The area is a rational area for thewecived "automatic" designation will (i) A majority of the facility's prmr delivery of dental services.be assigned to degree-of-shortage group care services are being provided to 2. One of the following conditions4 If no information on the ratio of the residents of designated pimary care prevails in the area:number of peinons in the group to the manpower sbortage areas or to (a) The area has a population to full.number of VFE primary care physicians population groups designated as having time-equivalent dentist ratio of at leastserving them is provided. . a shortage of primary care manpower, or SAW1. or

(1)Tepplainwti (b) The ares has a population to full.PAR!!I-aides, ignathed populatio wiehoth ge are time-equivalent dentist ratio of less than

A. Federal and Sotat Corretional designuatedn prm hasy creashortagle are 5001 but greater than 4.W001 and hasInsitorns pceso primatio vp hservieasnal unusally high needs for dental services

L. Criteria. aroviessa to e priaciiy. cReasonable . or insufficient capacity of existingMedium to maximum security Federal provs idled at smdi the failty reaso l dental providers.

and State correctional lnstilutions and wcteis whil bhe assumedIfthen aresieale 3. Dental manpower in contiguousyouth detention facilities wil be within whichuthes popuelatimeon r hesdsle areas are overutilized. excessivelydesignated as having a shortage of wailthiand n0omnuteysitravl barimofter distant. oir inaccessible to the population.,primary medical care manpower it bot freatiity ademon-aphyica bande of the area under consideration.

the following crtraa o:socioeconomic. characteristics ofted ethodolgy

itimates. inttto a tlat10 population) do not prevent the the criteria established by paragraph A(bhMerai of tenumber oC rpoulation frmreceiving care at the of thi Part, the following methodology

internees per year to the number of Fr fcliy wil be used.primary care physicians serving the Migrant health centers (as defined in 1. R atina Area for the Delivery ofinstitution is at least 1.000 (Hane the section 310(a)(1) of the Act) which are Dental Services.n~imbeir of internee" is the number of located in areas with designated migrant (a) The following areas will beinmiates present at the beginning of th population groups and Indian Health considered rational areas for theyear plus the number of now inmates Service facilities are assumed to be delivery of dental health services:entering the institution during the year, meeting this requiement. (i) A county. or a group of severalIncluding those who left before the end (b)lInsufficienti ca~pacity to awee contiguous counties whose populationof the year the number of PTE Priamar" rmr oe*d centors are within 40 minutrs travel timecame Physicians is computed easin Part L A facility will be considered to have of each other.Section 3& paragraph 3 above.) insufficient capacity to meet the primary (11) A portion of a county (or an area

2. Determnatio~n of Dgwre of care needs of the awea or population it made up of portions of more than oneShorageserves if at least two of the following county) whose population. because of

Designated correctional institutions conditions exist at the facility: topography, market or transportationwill be assigned to degree-of-shortage (i) There are mor than LOW0 patterns. distinctive populationgros based on the number of Inmates outpatient visits per year per MI characteristics, or other factors has

an/rthe ratio (R) of interne"s to primary cane physician on the staff of hainitad access to contiguous areaprimary care physicians. as follows: the facility. (Here the number of FMh resources. as measured generally by a&rou 1-inaututions with No or as primary care physicians is computed as travel time of greater than 40 minutes to

bmastse and so physicians. in Part L SectionS paragraph 3 above.) such resources.

Page 36: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

7VMO Federa Regist in Vol. 45. No. 223 1 Monday. November 17, 19W 1Rtules and Regulations

(ill) Established neighborhoods and the purposes of these determinations. an (b) The majority of the areas@commoniti es within metropolitan areas auxiliary is defined as any non-demtlut population does not have a fluaouidatedwhich display a sft"o self-Identity (as staff employed by the dentist to assist In wa:er supply.indicated by a hom~ogenous * openauon of the practice. * .& zeirminotiono f h&SUfffCierstsocioeconomic or demographic etutu C~apcity ofIExiortu Dental Ccamand/or a traditional of interction: or TO L t'kvkny Weigts, by Ag used pojintradependency). have limited Hu"o uf~ An area's odstin dents] canrinteraction with contiguous areas. ood CU 016 soO N providers will bi considered tj havewhidi In general. have a melaimum insufficient capacity if at least two ofpopulation of 2.000. otas a, us as the folloiog citeria are met

(b) Th. Wowin llg distances will be am _____ is :& : ILI (a) More than S=0 visits p. year perused as guidelines in determining 1" 1 A a soPE dentidst erving the area.distances corresponding to 4o mitnutes, '.me 0 OSOL- U. is %a %A , (b) Uinusually W4 waits fortravel lime. appointments o routine dental1 seviMe

(I) LUnde normial coddn witlo (L&.. saorv than$ weekis).primary rmads available-. 25 miles. If inflormtion on thle number of (c) A aubatmantisl proportion (% at

(II) In mountainous tw~ain or in areast auxiliaries employed by the dentist k more) of the area's dentists do notwith only secondary maede .availablr-w not available. Table 2 will be used to acenpt now patients.

miles.compute the number of ful-time &. singuous Ame Conridguiror.,

(oIe) In flat terrain orden areas Dautri manpower in areas contiguousconnected ~ ~ ~ ~ ~ Y byItrtt2iiras 0 TA EqAWeiWs7 WeightsyAe oa d res , be~iong considered for

miles_____________willha consideredWithin Inner portions ef metropolitan a ume soan ma* excessively distant. overutilized or

area" information on the public inaccessible to the population of thetransportation system will be used to 9* v-* is so as aol rea- un der consideration if one of thedetermine the distance corresponding to following conditions prevails in sack40 minutes travYel tim& The number of TIM dentists withla a coniguou aree:

L Populatfon COUBL particular age group for age! auxliary (a) Dental manpower in theThe population count use wigl be the grop) il be obtained by muldpipt cotiguous are are more than 40

total prmanent resident civilian the number of dentists within that grou mnthes travel time from the center ofpopulation of the area. exclud-n by lbs corresponding equivalency tea&bigcniee oinmates of institutions, with the weight. The total supply of TIM dentists designation (measured In accordance,following adjusmnents: withinan area It then computed as the wvith Paragraph 8.1.(b) of this Part.

(a) easnalresient. L, toss ho unsof tosedenist witin achage (b) Contiguous area population-to-maintainea residence in the area but agWeilaM ec'I T:dentist ratos arm in excess ofInhabit ft for only 2 toSa months per yea.(r ar2.000) rup &W 1. Indicating that resouarcestmay be Included but must be weigted (c) The equivalency weights specified contiguous areas cannot be expected toIn proportion to th frction 721 in tables I and 2 assumne that dentists help alleviate the shortage situation in

ame presn in the area. within a particlarI5 group am workin the area being considered for1 )Mgaoyworkert and their foll-tine (40 home pa week). Whene designation.

families may be included in an areas# appropriate data are available, adjusted (c) Dental manpower in thepouation using the following formula: equivalency figures for dentists who are contiguous area ans inaccessile Io, the

Effective migrant contribution to semi-retired, who operaetta reduced population of the area underpopulaltion-(fraction of yea -fp12 practice due to infirmity or other limilting consideration because of specifiedare present in aree)X (average daily condition&a. r who ane available to the access bazrrere. such as:number of migrants during pot tion of population of an area only on a part- (I) Significant differences be twee theyear that migrants are preseatt tim lasfs wil be used to reflect "h demographic (or socioeconomic)

& Countarg olDenta? Roctitimmm reduced availability of these dentists. am characteristics of the area under~(a) ADl nail-Federal detists providing computing these equivalency figurea., consideration snd thoe" of the

patient camewill be counted. except in every 4hours (or %day) spentin the contguouswa.. Indicating that thethose area wheoe it is shown tha dental practice will be counted as &I population of the area underspecialists (those dentists wo in gp.era 7M! except that each dentist workin consideration may be effectivelypractice or pedodootics) are servin a amot than 40 hours a week will be isolated boom aearby resources. Sucllarger area and are not addressing the caunfetd " 1A The count obtained tbrit isolation could be indicated, forgeneral dental care needs of the ame partculaorag group of dentist will then exml.b ,nsal higlounder consideretion. emutiplied by the appropriate proportion of zw-aiisbý-spea~inp

(b) Full..time equivalent WM I~e) fi equivalency weight frvom table I or a to persomwill be need to reflect productivity obtain a full-time equivalent figure for fil A lack of economic access Sodifferences among dental practices dentists within that particular upe or, contiguous area resources. particularlybased ort the age of the dentists, the age/auxdlary category. where a very high proportion of the

Inume of auxiliaries employed. and the 4L Daenwiarlctim of VpwainuaU 11W' populatioe of the ame undernumber of hoeom worked per week. to NJedotbrDeneialSrvicaut consideration is poor (Le.. where mwpotaerl. the aumber of YTL dentists wil An ares will be considered as havinq than W percent of the population or ofbe computed using weights obtained unusually high need for dental services the household ae noe below thefrom the matrix in Table I. which is if at least one of the follo wing Criteria Is poverty level) and Medicaidocovervd orbasel non the producrtivity of doctists as Nat public dental services are not availablevarious ages, with different numbers, &I (a) Mome theaa S of the population In the contiguosa arse.auxiliaries, as compared with thie (or of all households) has incomes Q. DceraiinewiON of Dgrowe o9averaei productivity of ali dontist. For below the pave. y leveL Shortage.

Page 37: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

Federal Register IVol. 45, No. 223 /Monday. November 17, 1980 Rules and Regulations 79005

T1e degree of shortage of a given auSln*J to degree-of-shortage group 4 care services are being provided togeographic anea, designated as having a unless information on the ratio of the residenta of designated dentalshortage of dental manpower. will be number of persons in the group to the manpower shortage areas or todetermined uaing "Ae following number of VFE dentists serving them is population groups designated as havingprocedure: provided, a shortage of dental manpower. or

Designated areas will be assigned to (II) The population within adegre.-of-ehortage groups. based on the PONt 51l-Focilities designated dental shortage ares orratio (R) o! population to number of full A. Meoral and State Correctional Population poop has reasonable accsbume-equivalent dentists and the hIrtiudoisw . to dental services provided at theprsence or absence of unusually high 1. Criteria. facility. Reasonable access will beneeds for dental ferVlI.V Of insufficient Medium to maximum security Fedu'ra assumed if the population lies within 40capacity of existin dental care and State correctional institutionsaend minutes travel time of the facility andproviders according to the following yuth detention facilities will beno-physical barriers (relating totable- designted as having a shortage of demographic and socioeconomic

_____________________ dental manpower if both the following cactristics )f the population) do notcriteria are met prevent the population from receiving

ewX~~v e~.mmv (a) The Institution has at least 250 care at the facility.unmates. Migrant health centers (as defined in

dmI- No ara bee (b) Theo ratio of the number of section 319(a)(1) of the Act) which areVa a Internees per year to the number of FITE located in areas with designated migrant

am a-A000O dentists serving the institution Is at leastpouaingused nanHlt40w A W>0eU _ 600>X4 15I00:1. Moar the number of internees is Service facilities are assumed to be

the number of inmates present at the meeting thws requirement.ha J.-.Ppultioa~,,beginning of the year plus the number of (b Im.ufficient Ccqpaciy to MeetP&IB-Ppuado GiLWnew inmates entering the institution Denta cc", JVftde

A. Citeria. dimszg the year. Including those who left A facility will be considered to have1. In general. specified population before the end of the year. the number of Insuffcient capacity to meet the dental

groups within patcua gegraphic PTM dentists is computed as in Par L ca needis of a designated arts orareas will be designated as having a Section A. paragraph 3 above.) populat grtoop if either of theshortag of dental care manpower if the I oi~~Detaniatonof -,f.1 follow~ing conditions exists at thefollowing three criteria arn ns DSiotgnaed coaecioalIitityo.

a. Te area In which they reside IS wilDeasignaed torderee-iof- ishiutortag (I Tm ar more than 5=0rational for the delivery of dental care wilb asge t ereo-h outpatient visits per year per VT!aervlces.uasdefinedin paragraph U Of groups as follow& based onnu = dentist on the staff of the facility. (HanePartlIof this appendix. Imtes and/or h aioC)o the number of FrE dentists Is computed

L. Access barriers prevent the as In Part L Section L. paragraph 3population group from use ofthe ara@ Group 1-Istitutionsswt W ts above.)dental provider. humates and no dentists. (U1) Walting time for appointments is

r- Ile ratio (R) of the number of c- 3...OthTinstitutions with so dentists ma tha 0 wek o routine dentalpersons In the population group to the li Inttuin wih > 3= services.number of dentists practicing in tthe mra Cru -otuinswhUW>R>I 3. DeterMurtio of DWWeeoand serving the population proop Is at IL PUblc or Non-Ptoft hitriats, Dental ShOflqg.least 4.00:1 Faciltiues. Each designated dental facility will be

3. Indians and Alaska Natives will be L Critea. assigned to the same degree-of-shortageconsidered for designation as having Public or nonprofit pOvate faciltes group as the designated Mares

sotgsof dental manpower asproviding general dental care services population group whicIt serves.foliowe: ~~~~will be designated as having a shortage ~frDsgaino

(a) Groups of membersof Indian of dental manpowerif both of the Apni -rtd o eiadootibee (as defined in section 4(d) of Pub. following criteria are met Amua havlag Shortage., of PsychiatricL 9-427. the Indasn Health Cane (a) Thes facility is providing general ManpowerImprovement Act of 1976 are dental care services to i.. area ovautomatically designated. population group designated as having a P~I-GDogiphc Area*

(h) Other groups of Indians or Alaska dental manpower shortage. end A rAHNatives ("s defined In section 4(c) of (b) The facility hos InsufficentA itraPub, L U-437) will be designated if the capacity to meet the dental cars needs A geographic area will be designatedgeneral criteria in paragraph I ar met. of that mra or population Woop as having a shortage of psychiatric

L. Deteuaaiont iý f Degre Lf2 Methodology. manpower If the following three criteriuAawqefe. ofIn determining whether public at ar met

Each designated population poo wil nonprofit private facilities meet the 1. The man Is a rational mra for thecriteria establishe by paragraph 3.1. of delivery of psychiatric services.be assigned toea dogre.f-ofhortaga thi pert, the follwing methodology will . L One of the following conditions,

group as follows: be used. prevails within the area:Group I-So dentists a R LU&5.8W (a) pmrovion of 'erv/oes to a (a) Themaea has a population to full-Grup-4 >femDoeignaotd Area or Population CrosV. time-euivalent psychiatrist ratio of at

cilp ~A facility wilbe considered to be least 200M.01 orCrip ~Rk~OProviding services to an ama or (b) Th aema her a population to full-

Population groups wifdch have received population group if either. time-euivalent psychialriet ratio of loes."automatic" designation will be (I) A majority of the facility's dental than 20.00=1 but greater than X0OOMI

0

Page 38: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

Iuas Fderal Resister IVoL 4&. No. Z!3 Monday. November 1?. 19W Rules and Regulations

and be* unusually high needs foe onsptin the rnubes of fiuflw-tl An ares will be considered to havepsychiatric survices. equivalent (TIE psychlstriate mauafly hlaneed fur psychiatric

3. Psychiatric manpower In contigw.a P1) Psychiatric residents will be services if two or mom o the followingarma are overutillsed. excessively Merited as 0.5 F-11 psychiatrists. criteria are owdistan~t or inaccessible in residents ad (ii) Graduates of foreign med"a (a) 20 percent of the population (cc ofthe area uuder coniaidration. schools who are not citizens or lawful a11 households) have incomes below the

2. MehotwOloy. permanent residents of th United pwvarty level. or the area has beenI* determ;inin whether an area meets States w~ill be excluded has designated assa poverty ame In

the criteria established by paragraph A psychiatrist counts. acodnc ihse Zo 42 of theof this Part, the following Methodology (WI Tht -I jgaduates of foreign, Community Mental Health Centers AcAwill be used: medical .-hoola who are citizans or (b) A young dependency ratio (ratio of

L RoI~wiol Aires for kh Delivey of lawful vermanent ms~denta of the children ander 19 t population 1644)1inhycho~rc~enas.United States. but do act have exceso of so percoL

P, a)Th Z folwgareas will be ani-esticled licenses to practice .(c) An aged dependency ratio (ratio ofconsidered ratio"~i areas for the meodicine, will be Lventad a" 0.5 FM persons aged 03 and over to popalationdalivery of psychiatric services: schIatrists. 154141 In excess of Z5 percent.

(I) An established mentwal ath Ib) Psychiatrists who are semi-rotired. (d) A high prevalence of alcoholism incatchment area. us designated in the who operate a reduced practice du# t*o the population. as Indicated, by a valueState Mental Health Plan under the Infirmity or other Lkniting conditions, or of o.21 for the catchment area's Indexgeneral criteria set forth in section 238 of who e vd patient care to the of relative alcoholism prevalence (asthe Community Mental Health Centers poultion of an a-ea only on a part- developed by the National Institute ofAct. Utio basis will be discounted thzrou&g Alcohol Abuse end Alceholism, for the

(II] A portion of en estah~llhad mantel the us of "fulltme equivalency" purposes of allocating funds eve 42health catchinent area whose Spree. A 40-hour work week will be US.sC. 4571).population. because of topography. used as "h standard for determining a. L r"tguourAie Cbmirwide~nAmarket and/or transportation patterns bulldun equivalents in thes cases. For Psychiatric manpower in areasor other factors, has limited access to prectttioners working less than a 40. contiguous to en area being consideredpsychiatric resuurcesin the rest of the hour week. every 4bowsn(or %day) for designation will be consdaredcatchment area, as mesasrd generally spent providing patient cars services in excesawely distant. overutilized atby a travel tims of prester than 40 ambulatory rqi inpatient settings will be inaccessiblel to the population of theminntea to these resources. counted as CA 71T. and each area under consideration if onm of the

(Hi) A county or metropolitan area peychiablast provid mg patient care 40 or following conditions prevails In eaclwl'lch contaIns more than on. mental mowe hours a week will be cojuted as contiguous area:health catchment area. where date ane IA FrL For cas.t whsr,ý data am (a) Psychiatrists tn the contiguousunavailable by individual critchment available only for hours providing care areaare more than 40 minutes travel

-arma In office settings. equivalencies will ba time from the center of the area being(b) Ithe following distznces wil be provided in guidelines. considered for designation (measured in

used as guidelines in determining (c) In some cases, psychiatrists accordance with paragraph 91(b) of thisdistances corresponding to 40 minutes located within an area may not be part).travel timer accessible to the general population of (b) Conft.gou arva population-to.FIM

(i) Under normal condcitionz with the area under consideration. psychiatrist ratios %:ý in excass ofprimary roads available. 23 mIles Allowances for psychiatrists working in Z.oooI* indicating that psychiatrist# in

(Uf) In mountainous terrain or in arees restricted facilities will be mde& onea contiguous areas cannot be expected towith onl secondary roads availble 20 case-by-case basis. Examples of help alleviate the shortage situation Inmiles restricted practices Include staff Soe an* for which designation Is being

(Wi In flat terrain or In areas positions in, correctional institutions. cosdeeconnectedl by interstate highway= 30 youth datenbion facilities. residential (c yhatcmnpwri

potVso erpltn Ws~n etr o mtoal contiguous areas are inaccessible to theWithin Innerdoso erpltn disturbed or mentally retarded children. poulation of the requested ares

an**a. information on the public and inpatient units of State or county b=cus .fgepaphic. culturaltransportation system will be used to mental hospitals. language or other bw~arrir or because ofdetermine the distance corresponding to (d) In cases where theme are mental residency restric ins of programs or40 minutes travel tim. *heat facilities or inetitutions pniig facilities providitng such manpower.

&. Population Count. both inpatient and outpatient services, C. Dertnto ofDe, ofIthe population count used wril be the those psychiatrists assigned to hfw

total Permanent ksilden., civilian outpatient or other abort-tem ca units~ Designated areas will be assigned fiepopulation of the ara. exchuding will be co-nted. If the psychiatric staff Is er*.i ~ t ge ups. based an theInmates of instittions. not specifically allocated to am sevc ratio (R) of population to number of FrE

L. Counting of Psyctibtdats. or the other, the number of psychiatrists psychiatrists and the presence orI&Is Ad non-Federal psychiatrists In short-term cure will be estimated na absec of unuavally high see1 forprovidn patent care Odretor ti the basia of the relative workload he pschiatric services according to theWnldn consultatioe and sueriion) web type of set"In&. folowing table:

In ambulatory or other short-term =1m Is) Psychiatrists who are suspendedsettings to residents of the area mm for a period of eighteen months or amore0than one-half day per week will =be under provision of the Medicare-

toutd. Those psychiatrisis UzU-N edcid Ami-Flmuid and Abuse Act am -f osf-s*Solel in adtmInistrtaftin research, and will not be waio Otod R- R,00 lA

isaching will be excluded. Adjustments om. Dettmialef oaoLAHa* u )i,0,2Aas

for th tollowing factors will be made In Abedjwfaa Ps ja~Ic Seivmcm_________

Page 39: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

Federal Reisete• Vol. 45, No. 223 Monda•, November 17. 1980 I Rules and Regulations 7W .7

hat D.-•tulotdn Groups Imate or residents and R >3A. (D) The population within aPopulation groups within particular Group - othe facilties, designated psychiatric shortage area or

catchment areas will be designated as L State and County Mental Hospitals. population group has reasonable accesshaving a psychiatric manpower shortage 1. Criteria. to psychiatric services provided at theif the following conditions prevail A State or county hospital will be facility. Such reasonable access will be

(a) Aoccw barriers prevent the designated as having a shortige of assumed it the population lies within 40"population group from using those psychiatric manpower if both of tie minutes travel time of the facility andpsychiatric manpowe which are present following criteria are met: nonphysical barriers (relating toin the area. and (a) The mental hospital has an .demographic and socioeconomic

(hi The ratio of the number of persons average daily inpatient census of at characteristics of the populatiun) do notIn the population group to the number Of least 100 and prevent the population from receivingFmE psychiatrists serving the populatinn (b) The number of workload units per care at the faciliy..group. and practicing within 40 minutes FITE psychiatrists available at the (hi Responsibility for Provision oftravel time of the center of the area hospital exceeds 300. where workload Service.where the population group resides. is at units n calculated using the following This condition wig be considered toleast 30.000:1 (ZM.o0:1 where unus~y formula: be met if the facility, by Federal or Statehigh needs for psychiatric services am Total workload units - average daily statute, administrative action, orIndictatd. inpatient census + 2 X (number of contractual agreement, has been given

B. Dteramnation of Doom of Inpatient admissions per year) +0.5 x responsibility for providing and/orshonw. (number of admissions to day care and coordinating psychiatric services for the

Designated population groups will be outpatient services per year) ana or population group, consistentassigned to degree-of-shortage groups as Z. Detiwomnation of.D.gree of with applicable State plans.in Section C of Part I of this Appendix. Shortage. (c) Insufficient Capacity to Meetbased on the ratio of the group's State or county mental hospitals will Psychiatric Needs.population to the number of be assigned to degree-of-shortage A facility will be considered to havepsychiatrists serving it. together with the groups. based on the ratio (R) of insufficient capacity to meet thepresence or absence of unusually hlgh workload units to number of FRE psychiatric needs of the area orneeds for psychiatric services among the psychiatrists, as follows: population it serves if.population group. Group 1-No psychiatrists. r R>I.j.a (i) There ae more than 3.000 patient

Group -1.-.m>R> 1.. visits per year per FTiE psychiatrist onPhi 10-Facilities Group 3-I.200> R>o. the staff ae under care at the facility, or

Group 4-4oo>R>an (ii) No psychiatrists am on the staffAt. Federi o andState Cawseiiona C. Community Mental Heulth Centers and this facility is the only facilityL riteuboia and Other Public or Nonprfit Private providing (or responsible for providing)M u maxi mt Facilities. services to the designated ana orMedSum to maximum security Federia 1 , population.

ed State correctional Institutions for c community mental health center &. Determination of Degre-f.adults or youth, and youth detention (CMC) authorized by Pub. L 94& or Shorte.faclities. will be designated as hatving 10, CI ).utoidbyP. . r / htddintd c:itwilfhoiti f opychiab ic manpower if other public or nonprofit private facility Each designated facility will beshbothag of hollowin criteria me Mgt Providing psychiatric services to an area assigned to the same degree-of-shortage(b ) The institution hat moe thame n or population group. may be designated group as the designated area or

ma)thes in as havin a shortage of psychiatric population group which it serves.(b)Theratio ofthe numberof manpower if the facility is providing (or

internes per year to the number of 1M is responsible for providing) psychiatric Appendix D-Crterlta for Designation ofin t pe serving the Institumtion is a services to an area or population group Ames Having Shortages of Vision Carepsychiatrists servin the institution Is at deintda vi pyh lc Ieno ,

least 2.000. (Here the number of designated as having a psychiatric UAOPOWerIntenees is the number of inmates or manpower shortnge, and the facility has Part/-..Grophic Aresm"residents present at the beginning of the insufficient capacity to meet theYear. plus the number of new inmiates or psychiatric needs of the area or A. Criteria.

population group. A geographic are& will be designatedresidents entering the institution during I . as having a shortage of vision carethe year. Includin those who left before In determining whether Cflics or manpower if the following three criteriaS the end of the yea. the number of FTi other public or nonprofit private an met:Psychiatrists is computed as In Part L facilities meet the criteria established in I. The area Is a rational aea for theSection a. paragraph 3 above.) paragraph C.1 of this Part, the following delivery of vision we services.

2.Dtnnatica of eree of methodology will be use& L The estimated number of optometric

Coe1ecoal facilities and youth (a) Povis•on of Services to o visits supplied by vision care manpowerdetentio1 .. facilities will be assigned to Dist4 Am Or PoPlaJio Gricu. In the area is less than the estimatedSderelof4]bodSrta oup. based on iM The facility will be considered to be requirements of the aea's population fordegree- ofh grloups , bnd asted rton {R providing services to a designated aen thee visits. and the computed shortagenmber of inmates and/ar the ratio JR) or population poop if either:. is at least I.500 optmetric visits.of Internees to FTE psychiatrists, as (i) A majority of the facility's , Vision care manpower infpsychiatric services am being provided contiguous aens are excessively

G10ap 1.-Facilities with 8W or son to residents of deslgnated psychiatric distant. ovartilized. or inaccessible tobImates or residmM• and o psyhiatrsaL. manpower shortage aeas or to the population of the area underGroup a-Othar faciliti" with so population groups designated as havi'g considmtion.PsYChlaulats and facilities with o00 or ame shortage of psychiatric manpowe. or 5 Methdlogy.

, m o f L

Page 40: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

30

Page 41: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

APPENDIX 8

Reporting Form for Number and Specialty of Each Practitioner,

by County Within 30 Miles of Post

31.

Page 42: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

N'. /

KI'

S

/

32

/

Page 43: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

W m m

060

4-j

L5

u -

i

In 14

~1~ ~ u33

Page 44: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

/K / j

a

Ii

34

/,

Page 45: apps.dtic.mil · psychiatric manpower, (4) vision care manpower, (5) podiatric manpower, (6) pharmacy manpower, and (7) veterinary manpower. The basic criteria for the dental manpower

I -

DFIL 4ED3

DT(i>