by Beth Blevins

In his first week as director of the Utah Office of Primary Care and Rural Health, Matt McCullough faced a potential crisis: a Rural Health Clinic (RHC) in the southeastern part of the state was in danger of losing federal certification. Fortunately, McCullough found the solution—obtaining a (GDSA).

“A Critical Access Hospital (CAH) in Southeast Utah had commenced building a new Rural Health Clinic (RHC), but they found out that the area in San Juan County, where it was being built, wasn’t inside a HPSA () designation,” McCullough said. “So last September they asked our office what we could do.”

Medically Underserved Areas/Populations

It all comes down to numbers—specifically what does and does not qualify geographically as a HPSA, McCullough explained. “To be a geographic HPSA, a county has to have a population-to-provider ratio of 3,500 to 1,” he said. “With 15,000 people in the entire county you only get four providers and then you don’t qualify for a HPSA anymore. San Juan County has a partial HPSA, but it doesn’t cover the area where the new RHC was being built.”

Without the HPSA designation, the new RHC would not have been certified by CMS, “and without that certification, they might not have been able to open or stay open for long, because they would lose all that funding,” McCullough said. To qualify for Medicaid reimbursement, normally RHCs have to be either in a HPSA or a Medically Underserved Area (MUA). But the third option, which not every state pursues, is GDSA certification, he said.

“This GDSA is a huge benefit to the state,” McCullough said. “It qualifies all frontier counties in the state as governor designated shortage areas. Some of our frontier counties are extremely frontier—less than two people per square mile, and they have a number of health disparities.” For example, San Juan County has a Native American population of 49%. Because of this, he said, “HRSA was able to approve the GDSA because these areas are extremely underserved.” And once states receive GDSA approval, it never has to be updated, he said.

Although he told the CAH that it might take up to a year to get the GDSA certification, Utah was able to get it in only three months, a speed McCullough attributes partly to the knowledge he had obtained in his prior job as Senior Research Analyst and Program Coordinator for Utah’s Primary Care Office (PCO), where his responsibilities included HPSA and MUA designations. Another part of that success, he said, was having the PCO and the State Office of Rural Health (SORH) in the same office. “Many SORHs work with RHCs but don’t know all the criteria of designated shortage areas,” he said. “You need a good combination of having SORHs and PCOs working together to get this done.”

Additionally, using a direct connection with the governor’s office helped move the process along more quickly. “I drafted the letter and had the executive director of our Department of Health send it to the governor’s office directly,” he said. “I think that helped, to have his approval come from our office. Our governor is very rural-friendly. The letter was signed and sent back to us to send on to HRSA in only two weeks.” It also helped, he said, that he wrote two letters—one to the governor that explained the process and why the certification was needed, and a second letter for the governor to sign to send to HRSA. “So he didn’t have to write it, which saved a couple months of time,” McCullough said.

Utah also got help from other SORHs and PCOs in how to pursue the certification. “We reached out to Oregon because they had recently done this and they gave me a copy of the letter they sent to their governor requesting the certification and the one they sent to HRSA,” he said. In addition, he found examples of GDSA request letters from other states online. “I took those letters and pulled out the things that I felt would pertain to Utah the most and wrote a letter that made the most sense for Utah.”

Now that the GDSA certification is in place, McCullough said he has already begun to hear from hospitals in the state requesting GDSA approval for their clinics, and he imagines that his office will have one or two requests a year for it.

McCullough recommends that other states think about pursuing GDSA certification. (According to HRSA, only —plus Utah—now have GDSA certification.) “I’d be more than happy to help them and share the letters we wrote,” he said. “Having those letters is an important first step. Second is figuring out what works for your state. I didn’t use the numbers given in the other letters. I looked at each frontier county in Utah, to see how many could qualify, and adjusted the numbers to make it as beneficial as possible for our state. That’s where I’d be happy to provide guidance and share what worked best for Utah.”

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