National Health Service Corps Scholarship Research Articles

Is It Time to Expand the National Health Service Corps Scholarship Program to Address the Rural Emergency Medicine Physician Shortage?

Is It Time to Expand the National Health Service Corps Scholarship Program to Address the Rural Emergency Medicine Physician Shortage?

Expanding the National Health Service Corps Scholarship Program to General Surgery

Expanding the National Health Service Corps Scholarship Program to General Surgery

Nurse‐Midwives in Federally Funded Health Centers: Understanding Federal Program Requirements and Benefits

Midwives are working in federally funded health centers in increasing numbers. Health centers provide primary and preventive health care to almost 20 million people and are located in every US state and territory. While health centers serve the entire community, they also serve as a safety net for low-income and uninsured individuals. In 2010, 93% of health center patients had incomes below 200% of the Federal Poverty Guidelines, and 38% were uninsured. Health centers, including community health centers, migrant health centers, health care for the homeless programs, and public housing primary care programs, receive grant funding and enjoy other benefits due to status as federal grantees and designation as federally qualified health centers. Clinicians working in health centers are also eligible for financial and professional benefits because of their willingness to serve vulnerable populations and work in underserved areas. Midwives, midwifery students, and faculty working in, or interacting with, health centers need to be aware of the regulations that health centers must comply with in order to qualify for and maintain federal funding. This article provides an overview of health center regulations and policies affecting midwives, including health center program requirements, scope of project policy, provider credentialing and privileging, Federal Tort Claims Act malpractice coverage, the 340B Drug Pricing Program, and National Health Service Corps scholarship and loan repayment programs.

Critical factors for designing programs to increase the supply and retention of rural primary care physicians.

The Physician Shortage Area Program (PSAP) of Jefferson Medical College (Philadelphia, Pa) is one of a small number of medical school programs that addresses the shortage of rural primary care physicians. However, little is known regarding why these programs work. To identify factors independently predictive of rural primary care supply and retention and to determine which components of the PSAP lead to its outcomes. Retrospective cohort study. A total of 3414 Jefferson Medical College graduates from the classes of 1978-1993, including 220 PSAP graduates. Rural primary care practice and retention in 1999 as predicted by 19 previously collected variables. Twelve variables were available for all classes; 7 variables were collected only for 1978-1982 graduates. Freshman-year plan for family practice, being in the PSAP, having a National Health Service Corps scholarship, male sex, and taking an elective senior family practice rural preceptorship (the only factor not available at entrance to medical school) were independently predictive of physicians practicing rural primary care. For 1978-1982 graduates, growing up in a rural area was the only additionally collected independent predictor of rural primary care (odds ratio [OR], 4.0; 95% CI, 2.1-7.6; P<.001). Participation in the PSAP was the only independent predictive factor of retention for all classes (OR, 4.7; 95% CI, 2.0-11.2; P<.001). Among PSAP graduates, taking a senior rural preceptorship was independently predictive of rural primary care (OR, 2.5; 95% CI, 1.3-4.7; P =.004). However, non-PSAP graduates with 2 key selection characteristics of PSAP students (having grown up in a rural area and freshman-year plans for family practice) were 78% as likely as PSAP graduates to be rural primary care physicians, and 75% as likely to remain, suggesting that the admissions component of the PSAP is the most important reason for its success. In fact, few graduates without either of these factors were rural primary care physicians (1.8%). Medical educators and policy makers can have the greatest impact on the supply and retention of rural primary care physicians by developing programs to increase the number of medical school matriculants with background and career plans that make them most likely to pursue these career goals. Curricular experiences and other factors can further increase these outcomes, especially by supporting those already likely to become rural primary care physicians.

Commentary From the Front Lines: Improving the National Health Service Corps' Use of Medical Providers

Abstract: Migrant and community health centers, funded by the Bureau of Primary Health Care (BPHC), provide a vital service to rural communities by ensuring accessible and affordable medical care. One way the BPHC helps communities staff these centers is through the National Health Service Corps (NHSC). In this program, medical professionals receive scholarships or educational loan repayment in return for practicing in medically underserved regions where migrant and community health centers are located. Nurse practitioners, physician assistants, and nurse midwives (nonphysician providers) are a recent addition to the NHSC, and they offer the advantages of reduced cost and a strong primary care orientation. In this commentary, the authors recount their own experiences as a nonphysician provider NHSC scholarship recipient and spouse, and they identify five underlying problems with the current system, which lead to poor nonphysician provider retention. (1) Too few potential placement sites are made available from the outset. (2) NHSC placement deadlines do not allow enough time for making the best possible placement. (3) Many community health centers are not highly supportive of or invested in the program. (4) NHSC efforts to support the development of local medical providers from within underserved regions are inadequate. (5) NHSC officers working with nonphysician providers do not demonstrate a high degree of commitment to achieving an optimal provider‐site match. Changes in the NHSC program based on these five problems are recommended to improve the retention of nonphysician providers in this important program.

The National Health Service Corps: rural physician service and retention.

The National Health Service Corps (NHSC) scholarship program is the most ambitious program in the United States designed to supply physicians to medically underserved areas. In addition to providing medical service to underserved populations, the NHSC promotes long-term retention of physicians in the areas to which they were initially assigned. This study uses existing secondary data to explore some of the issues involved in retention in rural areas. The December 1991 American Medical Association (AMA) Masterfile was used to determine the practice location and specialty of the 2903 NHSC scholarship recipients who graduated from US medical schools from 1975 through 1983 and were initially assigned to nonmetropolitan counties. We used the AMA Masterfile to determine what percentage of the original cohort was still practicing in their initial county of assignment and the relation of original practice specialty and assignment period to long-term retention. Twenty percent of the physicians assigned to rural areas were still located in the county of their initial assignment, and an additional 20 percent were in some other rural location in 1991. Retention was highest for family physicians and lowest for scholarship recipients who had not completed residency training when they were first assigned. Retention rates were also higher for those with longer periods of obligated service. Substantial medical care service was provided to rural underserved communities through obligated and postobligation service. Nearly 20 percent of all students graduating from medical schools between 1975 and 1983 who are currently practicing in rural counties with small urbanized populations were initially NHSC assignees. Although most NHSC physicians did not remain in their initial rural practice locations, a substantial minority are still rural practitioners; those remaining account for a considerable proportion of all physicians in the most rural US counties. This study suggests that rural retention can be enhanced by selecting more assignees who were committed to and then completed family medicine residencies before assignment.

Minority Physicians Serving in Rural National Health Service Corps Sites

Providing National Health Service Corps (NHSC) scholarships to under-represented minorities has been an important federal mechanism to bolster the numbers of minority physicians. Little is known about how minorities fare during their NHSC commitment periods. In 1991, questionnaires were mailed to all primary care physicians placed in rural communities from 1987 through 1990 in the NHSC scholarship program, in a retrospective cohort study. One hundred and twenty-two of the 398 eligible NHSC physician respondents (31%) indicated they were minorities. National Health Service Corps physicians were found to be well matched by race to the sites where they served, and minority NHSC physicians worked in counties and practices with greater proportions of minority inhabitants and patients. Minorities among rural NHSC physicians were less likely to have been raised in rural areas and were less interested in rural practice during medical school and when placed in their rural NHSC sites. The relative urban preferences of minority physicians in large part explains why this group was more dissatisfied with their work and personal lives while serving their obligations. Minority physicians also reported lower satisfaction for their families. Minority and nonminority NHSC physicians reported comparable acceptance by their communities, and demonstrated similarly low retention rates. The NHSC plays a significant role in the careers of many young minority physicians and in promoting the temporary availability of minority physicians for rural health professional shortage areas. However, as of 1991, many minority NHSC physicians placed in rural areas would have preferred urban sites, which resulted in their lower satisfaction.

The Comparative Retention of National Health Service Corps and Other Rural Physicians

To contrast the retention of physicians serving National Health Service Corps (NHSC) Scholarship Program obligations in rural settings to that of non-NHSC physicians working in the same or similar practices, and to identify promising retention-enhancing strategies. Cohort study. Four hundred twelve primary care physicians initially identified during an earlier study as working in a national stratified random sample of 178 externally subsidized rural clinics in 1981. Thirty-six percent were serving obligations to the NHSC, nearly all through the NHSC's Scholarship Program. The NHSC and non-NHSC inception cohorts (those first coming to their 1981 [or "index"] practices from May 1979 through December 1981) were created from within the entire group for use in most analyses. In 1990, physicians were resurveyed to learn of their backgrounds, experiences in their index practices, and their subsequent career moves. By 1984 and in each year thereafter, fewer NHSC than non-NHSC physicians of the entire respondent cohort remained (1) in their index practices, (2) in their index communities, and (3) in practice in any rural county (P less than .001). In the inception cohort, fewer NHSC than non-NHSC physicians were retained within all three settings by the third year after their initial dates of employment (P less than or equal to .01). After 8 years of employment, group retention rates for NHSC and non-NHSC inception cohort physicians were 12% vs 39% in the index practice and 29% vs 52% in nonmetropolitan practice. Physicians in both NHSC and non-NHSC groups who left their index practices generally left rural practice altogether. When compared to non-NHSC physicians working in comparable rural settings, the retention of rural NHSC physicians is seen to be poor and only partially explained by fixed physician, practice, or community variables. Long-term retention of NHSC providers is now receiving much needed attention at the federal level.

The comparative retention of National Health Service Corps and other rural physicians. Results of a 9-year follow-up study

<h3>Objective.</h3> —To contrast the retention of physicians serving National Health Service Corps (NHSC) Scholarship Program obligations in rural settings to that of non-NHSC physicians working in the same or similar practices, and to identify promising retention-enhancing strategies. <h3>Design.</h3> —Cohort study. <h3>Participants.</h3> —Four hundred twelve primary care physicians initially identified during an earlier study as working in a national stratified random sample of 178 externally subsidized rural clinics in 1981. Thirty-six percent were serving obligations to the NHSC, nearly all through the NHSC's Scholarship Program. The NHSC and non-NHSC inception cohorts (those first coming to their 1981 [or "index"] practices from May 1979 through December 1981) were created from within the entire group for use in most analyses. <h3>Intervention.</h3> —In 1990, physicians were resurveyed to learn of their backgrounds, experiences in their index practices, and their subsequent career moves. <h3>Results.</h3> —By 1984 and in each year thereafter, fewer NHSC than non-NHSC physicians of the entire respondent cohort remained (1) in their index practices, (2) in their index communities, and (3) in practice in any rural county (<i>P</i>&lt;.001). In the inception cohort, fewer NHSC than non-NHSC physicians were retained within all three settings by the third year after their initial dates of employment (<i>P</i>≤.01). After 8 years of employment, group retention rates for NHSC and non-NHSC inception cohort physicians were 12% vs 39% in the index practice and 29% vs 52% in nonmetropolitan practice. Physicians in both NHSC and non-NHSC groups who left their index practices generally left rural practice altogether. <h3>Conclusions.</h3> —When compared to non-NHSC physicians working in comparable rural settings, the retention of rural NHSC physicians is seen to be poor and only partially explained by fixed physician, practice, or community variables. Long-term retention of NHSC providers is now receiving much needed attention at the federal level. (<i>JAMA</i>. 1992;268:1552-1558)

Patients Leaving Emergency Departments Without Being Seen by a Physician-Reply

In Reply. —Several points are raised in these letters that require a response. It is ironic that funding for the National Health Service Corps Scholarship program has been curtailed at a time when the need for primary care practitioners in physician shortage areas is greater than ever. The alternative of paying a bonus, instituting debt forgiveness, or providing tax incentives to physicians who choose to locate in such areas is an intriguing concept that merits further consideration. As an active practitioner, I also fear frivolous lawsuits, but I have grave reservations about a system of arbitration or review that would be imposed only on the poor. If an approach to tort reform that is fair to patients and providers alike can be found, it should be applied to all. The shrinking number of primary care practitioners able or willing to provide care to the poor is clearly exacerbating our

Physicians for Rural Areas

To the Editor.— Peter Barna's 1 proposal to match new physician supply with rural demand in exchange for loan forgiveness is well taken by this medical student. I have few resources for aid other than insufficient guaranteed student loans and bank loans, which incur debt very quickly. Unfortunately, I will probably be influenced by this debt in my choice of specialty and practice location (ie, urban) even though I would enjoy working in a small rural community. Working as a volunteer in Appalachia made me aware of the great need for medical care in rural America. However, practicality will most likely replace idealism until my bills are paid. In lieu of the National Health Service Corps Scholarship Program, which is no longer available, I propose that the Preferred Placement Program, now offered to students of the Medical College of Ohio at Toledo, be expanded to a larger regional or even national

Allegiance to the Corps

IN RESIDENCY training programs around the country, a wave of physicians with obligations to the National Health Service Corps (NHSC) is now cresting. These physicians held NHSC scholarships as medical students, and on completion of residency training approved by the Corps they must begin a period of service equal in years to the length of time that they were supported by the NHSC as medical students. The recipients of the last large batch of NHSC scholarships were freshmen in medical school four years ago and are now in their first year of residency training. The wave of NHSC scholarship students has already passed through the medical schools, and by 1987 it will have passed through most residencies as well. Thereafter, communities that would have trouble attracting physicians without the special inducement of the NHSC service obligation may find themselves medically abandoned. This article proposes a strategy for averting that predictable

National Health Service Corp: a survey of Alabama's scholarship recipients.

In April 1979, 41 Alabama medical students who had received scholarships from the National Health Service Corps (NHSC) were surveyed. The students were predominantly single urban individuals who received their initial NHSC scholarship in the first or second year of medical school. The majority who planned primary care careers were undecided about remaining in the NHSC after their commitment. The students were concerned about the logistics of the NHSC and practice in rural areas. Based on their response, it is suggested that medical schools, The American Medical Student Association, and the NHSC develop a series of activities designed to facilitate the NHSC scholarship recipients subsequent activities in the NHSC. These suggestions include elective credit for NHSC/AMSA (American Medical Student Association) preceptorships, curriculum offering that facilitate the physician's practice in underserved communities, and activities that facilitate the medical school faculties' understanding of the NHSC.

Service-conditional medical student aid programs: The experience of the states.

Medical student aid programs tied to a service commitment are in operation in 31 states. The programs provide various options for students to pay back the financial support given by the state, the most popular form being cancellation of the financial obligation to the the state if a service commitment is fulfilled. Although the statutory language and program literature claim a major objective of the programs to be the provision of manpower to underserved areas, lenient "buy-out" provisions and small awards relative to the total tuition have caused these programs to be used as sources of low-interest loans. Moreover, states do not provide subsidies to promote service in unattractive areas; thus, there is little reason for physician graduates to locate in low-income areas. State cooperation with the federal National Health Service Corps Scholarship Program, which does provide subsidies to physicians practicing in underserved areas, may provide the states a strategy for meeting their legislative objectives of providing physicians for the underserved.

Sounding Board. A Federal Health Service Corps.

The National Health Service Corps (NHSC) scholarship program is a moribund child. The month of its death is predictable. In June of 1985 the small group of medical students who obtained NHSC scholarships as first-year students in 1981 will graduate — barring a few stragglers and dropouts — and the National Health Service Corps scholarship program will expire at the age of 11 years. Only a handful of medical students obtained new NHSC scholarships this year. Being in exceptional financial need, they qualified for a last burst of new scholarships issued with unspent funds carried over from the previous fiscal . . .