National Health Service Corps Research Articles

Buprenorphine Prescribing and Challenges Faced Among National Health Service Corps Clinicians

The National Health Service Corps (NHSC) Loan Repayment Program (LRP) expansion in fiscal year (FY) 2019 intended to improve access to medication for opioid use disorder (MOUD) by adding more clinicians who could prescribe buprenorphine. However, some clinicians still face barriers to prescribing, which may vary between rural and nonrural areas. To examine the growth in buprenorphine prescribing by NHSC clinicians for Medicaid beneficiaries during the NHSC LRP expansion and describe the challenges to prescribing that persist in rural and nonrural areas. This cross-sectional study analyzed preexpansion and postexpansion Medicaid claims data to evaluate the percentage of prescriptions of buprenorphine filled during FY 2017 through 2021. This study also analyzed challenges and barriers to prescribing MOUD between rural and urban areas, using results from annual surveys conducted with NHSC clinicians and sites from FY 2019 through FY 2021. Prescribing of buprenorphine by NHSC clinicians. The main outcomes were the percentage and number of Medicaid beneficiaries with opioid use disorder (OUD) who filled a prescription for buprenorphine before and after the LRP expansion and the challenges NHSC clinicians and sites faced in providing substance use disorder and OUD services. Survey results were analyzed using descriptive statistics. During FYs 2017 through 2021, 7828 NHSC clinicians prescribed buprenorphine (standard LRP: mean [SD] age, 38.1 [8.4] years and 4807 females [78.9%]; expansion LRPs: mean [SD] age, 39.4 [8.1] years and 1307 females [75.0%]). A total of 3297 NHSC clinicians and 4732 NHSC sites responded to at least 1 survey question to the 3 surveys. The overall percentage of Medicaid beneficiaries with OUD who filled a prescription for buprenorphine during the first 2.5 years post expansion increased significantly from 18.9% before to 43.7% after expansion (an increase of 123 422 beneficiaries; P < .001). The percentage more than doubled among beneficiaries living in areas with a high Social Vulnerability Index score (from 17.0% to 36.7%; an increase of 31 964) and among beneficiaries living in rural areas (from 20.8% to 55.7%; an increase of 45 523). However, 773 of 2140 clinicians (36.1%; 95% CI, 33.6%-38.6%) reported a lack of mental health services to complement medication for OUD treatment, and 290 of 1032 clinicians (28.1%; 95% CI, 24.7%-31.7%) reported that they did not prescribe buprenorphine due to a lack of supervision, mentorship, or peer consultation. These findings suggest that although the X-waiver requirement has been removed and Substance Abuse and Mental Health Services Administration guidelines encourage all eligible clinicians to screen and offer patients with OUD buprenorphine, as permissible by state law, more trained health care workers and improved care coordination for counseling and referral services are needed to support comprehensive OUD treatment.

Racial and Ethnic Concordance Between National Health Service Corps Clinicians and Underserved Populations

Despite the widely recognized importance of racial and ethnic concordance between patients and clinicians, there is a lack of studies on clinician diversity in medically underserved areas and whether it aligns with the changing demographic landscape. To assess trends in National Health Services Corps (NHSC) clinician diversity and racial and ethnic concordance between NHSC clinicians and the populations in underserved areas from before to after the 2009 NHSC expansion. This cross-sectional, population-based study compared trends in the diversity of NHSC clinicians practicing in health professional shortage areas (HPSAs) and the HPSA populations during 2003 to 2019 using the Health Resources and Services Administration's NHSC Field Strength Database and Area Health Resources Files. The analysis was performed from February through May 2023. Concordance was measured with an annual community representativeness ratio defined as the ratio of the proportions of same race or ethnicity NHSC clinicians to HPSA population. There were a total of 41 180 clinicians practicing in HPSAs from 2003 to 2019; the median (IQR) age was 34 (30-41) years. Among 38 569 NHSC clinicians who reported gender, 28 444 (73.7%) identified as female and 10 125 (26.3%) identified as male. The average annual number of NHSC clinicians increased from 3357 in 2003 to 2008 to 9592 in 2009 to 2019. Before 2009, 1076 clinicians (5.3%) identified as Black, 9780 (48.6%) as Hispanic, 908 (4.5%) as other, and 8380 (41.6%) as White. During this period, concordance was low among non-Hispanic White and Black individuals due to clinician underrepresentation relative to the population, yet Hispanic clinicians were overrepresented. Following the 2009 NHSC expansion, the main change was the sharp decline in the proportion of Hispanic clinicians, to 1601 (13%) by 2019; while concordance was achieved for non-Hispanic White and Black individuals, Hispanic clinicians became underrepresented relative to population. The results held across 3 specialties: primary care, mental health care, and dental care. This cross-sectional study of trends in racial and ethnic concordance found that while the NHSC expansion starting in 2009 improved clinician-population concordance for non-Hispanic White and Black individuals, it reversed a prior trend for Hispanic individuals among whom clinicians became underrepresented relative to the population. Targeted NHSC clinician recruitment efforts are needed to improve concordance for Hispanic individuals in underserved areas, especially given Hispanics' projected growth in the US.

Impact of U.S. Federal Loan Repayment Programs on the Behavioral Health Workforce: Scoping Review.

Federal loan repayment programs (LRPs) are one strategy to address the shortage of behavioral health providers. This scoping review aimed to identify and characterize the federal LRPs' impact on the U.S. behavioral health workforce. A scoping review was conducted in accordance with JBI (formerly known as the Joanna Briggs Institute) methodology for scoping reviews. The authors searched the Ovid MEDLINE, Web of Science, APA PsycInfo, EconLit, PAIS Index, and Embase databases, and gray literature was also reviewed. Two coders screened each article's abstract and full text and extracted study data. Findings were narratively synthesized and conceptually organized. The full-text screening identified 17 articles that met eligibility criteria. Of these, eight were peer-reviewed studies, and all but one evaluated the National Health Service Corps (NHSC) LRP. Findings were conceptually organized into five categories: descriptive studies of NHSC behavioral health needs and the NHSC workforce (k=4); providers' perceptions of, and experiences with, the NHSC (k=2); associations between NHSC funding and the number of NHSC behavioral health providers (k=4); NHSC behavioral health workforce productivity and capacity (k=3); and federal LRP recruitment and retention (k=4). The literature on federal LRPs and their impact on the behavioral health workforce is relatively limited. Although federal LRPs are an important and effective tool to address the behavioral health workforce shortage, additional federal policy strategies are needed to attract and retain behavioral health providers and to diversify the behavioral health workforce.

Preparing behavioral health clinicians for success and retention in rural safety net practices.

This study assesses how, among behavioral health clinicians working in rural safety net practices, the amount of exposure to care in rural underserved communities received during training relates to confidence in skills important in their work settings, successes in jobs and communities, and anticipated retention. This study uses survey data from Licensed Clinical Social Workers, Licensed Professional Counselors, and Psychologists working in rural safety net practices in 21 states while receiving educational loan repayment support from the National Health Service Corps, from 2015 to April 2022. Of the 778 survey respondents working in rural counties, 486 (62.5%) reported they had formal education experiences with medically underserved populations during their professional training, for a median of 47 weeks. In analyses adjusting for potential confounders, the estimated amount of rural training exposure was positively associated with a variety of indicators of clinicians' integration and fit with their communities as well as with longer anticipated retention within their rural safety net practices. The amount of training in care for rural underserved populations was not associated with clinicians' confidence levels in various professional skills or successes in their work, including connection with patients and work satisfaction. Formal training in care for underserved populations is a large part of the education of behavioral health clinicians who later work in rural safety net practices. More training in rural underserved care for these clinicians is associated with greater integration and fit in their communities and longer anticipated retention in their practices, but not with skills confidence or practice outcomes.

Undue Burden the Medical School Application Process Places on Low-Income Latinos

Undue Burden the Medical School Application Process Places on Low-Income Latinos

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?

45.4 From the National Health Service Corps to Project ECHO: Leveraging Relationships and Consultation to Reach Underserved Populations

45.4 From the National Health Service Corps to Project ECHO: Leveraging Relationships and Consultation to Reach Underserved Populations

Continuing Investment in the National Health Service Corps is Vital for Addressing Workforce Shortages and Improving Diversity Among Clinicians

Continuing Investment in the National Health Service Corps is Vital for Addressing Workforce Shortages and Improving Diversity Among Clinicians

Impact of Service-Based Student Loan Repayment Program on the Primary Care Workforce.

As the average level of medical education indebtedness rises, physicians look to programs such as Public Service Loan Forgiveness (PSLF) and National Health Service Corps (NHSC) to manage debt burden. Both represent service-dependent loan repayment programs, but the requirements and program outcomes diverge, and assessing the relative uptake of each program may help to inform health workforce policy decisions. We sought to describe variation in the composition of repayment program participant groups and measure relative impact on patient access to care. In this bivariate analysis, we analyzed data from 10,677 respondents to the American Board of Family Medicine's National Graduate Survey to study differences in loan repayment program uptake as well as the unique participant demographics, scope of practice, and likelihood of practicing with a medically underserved or rural population in each program cohort. The rate of PSLF uptake tripled between 2016 and 2020, from 7% to 22% of early career family physicians, while NHSC uptake remained static at 4% to 5%. Family physicians reporting NHSC assistance were more likely than those reporting PSLF assistance to come from underrepresented groups, demonstrated a broader scope of practice, and were more likely to practice in rural areas (23.3% vs 10.8%) or whole-county Health Professional Shortage Areas (12.5% vs 3.7%) and with medically underserved populations (82.2% vs 24.2%). Although PSLF supports family physicians intending to work in public service, their peers who choose NHSC are much more likely to work in underserved settings. Our findings may prompt a review of the goals of service loan forgiveness programs with potential to better serve health workforce needs.

Rural communities and health professional shortage areas (HPSA) and access to immune effector cellular therapy and lymphoma/myeloma clinical trials.

e18633 Background: The National Health Service Corps (NHSC) has created a shortage designation to identify medically underserved communities. HPSA (Health Professional Shortage Areas) designation identifies an area, population, or facility with inadequate access to healthcare resources such as primary care. Rural-urban continuum codes (RUCC) classify U.S. census tracts using urbanization, population density, and daily commuting. Additionally, there are racial, ethnic, and geographic disparities in enrollment on therapeutic cancer clinical trials. Chimeric antigen receptor T cell (CAR T) therapy has been at the forefront of immune effector cell therapy (IEC) for lymphoma and myeloma. However, it is delivered at specialized centers, and access to specialty centers is known to be a challenge due to financial and geographic barriers. At our institution, trials for CAR-T cell therapy in lymphoma and myeloma are conducted by the IEC disease working group (DWG), while non-IEC trials are conducted by the lymphoma/myeloma DWG. We hypothesized that patients from HPSA and rural communities and HPSA had lower access to IEC and non-IEC trials for lymphoma and myeloma . Methods: Patients enrolled between 1/1/2015 – 2/6/2023 on IEC and non-IEC interventional trials with treatment were included. Disease types included lymphoma (Follicular lymphoma, high-grade B cell lymphoma, diffuse large B cell lymphoma) and myeloma were included. The hypothesis was tested through a t-test. Results: There were 667 total subjects. 503 (75.4%) were non-IEC and 96 (14.3%) were IEC clinical trial participants. The majority in both groups were male (52.7%), White (74.8%), non-Hispanic (86%) .Only 69 (10.3%) pts were from rural areas and 223 (38.9%) were from HPSA communities When stratifying based on RUCC (Table), there is significantly higher rural accrual for IEC trials compared to non-IEC trials. Hispanics from rural areas were lower. There were no African Americans (AA) from rural areas. Conclusions: There is low representation of patients from HPSA and rural communities for IEC and non-IEC lymphoma and myeloma clinical trials. The ethnic and racial inequity in access and enrollment to lymphoma/myeloma trials are pronounced in rural and HPSA communities. Strategies to improve clinical trial enrollment of the underserved rural and HPSA populations is an area of unmet need and will benefit minorities and patients from lower socioeconomic status. [Table: see text]

Lessons From the Delta.

Lessons From the Delta.

Editorial introductions.

Editorial introductions.

Editorial introduction

Editorial introduction

Cost-effectiveness of Dental Workforce Expansion Through the National Health Service Corps and Its Association With Oral Health Outcomes Among US Children

Despite considerable efforts to improve oral health for all, large disparities remain among US children. A dental professional shortage is thought to be among the determinants associated with oral health disparities, particularly for those residing in underserved communities. To evaluate the cost-effectiveness of expanding the dental workforce through the National Health Service Corps (NHSC) and associations with oral health outcomes among US children. A cost-effectiveness analysis was conducted to estimate changes in total costs and quality-adjusted life years (QALYs) produced by increasing the NHSC funding for dental practitioners by 5% to 30% during a 10-year period. A microsimulation model of oral health outcomes using a decision analytic framework was constructed based on oral health and dental care utilization data of US children from 0 to 19 years old. Data from the nationally representative National Health and Nutrition Examination Survey (NHANES, 2011-2016) were linked to county-level dentist supply and oral health professional shortage areas (HPSAs) information. Changes in prevalence and cumulative incidence of dental caries were also estimated. Sensitivity analyses were conducted to assess the robustness of results to variation in model input parameters. Data analysis was conducted from August 1, 2021, to November 1, 2022. Expanding dental workforce through the NHSC program. Changes in total QALYs, costs, and dental caries prevalence and cumulative incidence. This simulation model informed by NHANES data of 10 780 participants (mean [SD] age, 9.6 [0.1] years; 5326 [48.8%] female; 3337 [weighted percentage, 57.9%] non-Hispanic White individuals) found that when funding for the NHSC program increased by 10%, dental caries prevalence and total number of decayed teeth were estimated to decrease by 0.91 (95% CI, 0.82-1.00) percentage points and by 0.70 (95% CI, 0.62-0.79) million cases, respectively. When funding for the NHSC program increased between 5% and 30%, the estimated decreases in number of decayed teeth ranged from 0.35 (95% CI, 0.27-0.44) to 2.11 (95% CI, 2.03-2.20) million cases, total QALY gains ranged from 75.76 (95% CI, 59.44-92.08) to 450.50 (95% CI, 434.30-466.69) thousand QALYs, and total cost savings ranged from $105.53 (95% CI, $70.14-$140.83) to $508.23 (95% CI, $598.91-$669.22) million among children residing in dental HPSAs from a health care perspective. Benefits of the intervention accrued most substantially among Hispanic children and children in low-income households. This cost-effectiveness analysis using a decision analytic model suggests that expanding the dental workforce through the NHSC program would be associated with cost savings and a reduced risk of dental caries among children living in HPSAs.

Role of the National Health Service Corps in Delivering Substance Use Disorder Treatment in Underserved Communities.

To help address the opioid epidemic, the U.S. Health Resources and Services Administration expanded the National Health Service Corps (NHSC) to include two new loan repayment programs (LRPs)-the Substance Use Disorder LRP and the Rural Community LRP-to supplement the existing standard LRP. In this article, the authors aimed to describe the role of these NHSC programs in addressing workforce shortages and providing substance use disorder treatment, including for opioid use disorder, in underserved areas. Administrative data on NHSC clinician locations were merged with county-level data to characterize the communities served by NHSC clinicians. Primary data from surveys and key informant interviews with NHSC site administrators (N=9) and clinicians (N=9) were used to describe changes in NHSC clinician service delivery due to the COVID-19 pandemic. The NHSC LRP expansion increased the number of clinicians providing behavioral health treatment in underserved areas, especially rural areas. A majority of NHSC sites surveyed have increased their provision of substance use disorder treatment since the COVID-19 pandemic began. This article demonstrates the valuable role of these NHSC programs as resources that policy makers can use to mitigate the challenges of health care workforce shortages and burnout.

Editorial introductions.

Editorial introductions.

Outcomes of States' Loan Repayment and Forgiveness Programs From the Perspective of Safety Net Practice Administrators.

Nearly every state offers loan repayment (LRP) and some offer loan forgiveness to clinicians who commit to work in safety net practices. The effectiveness of these programs from the perspective of safety net practices is largely unknown. OBJECTIVES: To assess safety net practice administrators' assessments of key outcomes for the 3 principal types of state service programs: LRPs funded by states, LRPs funded jointly by states and National Health Service Corps, and loan forgiveness programs. SUBJECTS: Administrators of safety net sites where primary care, behavioral health and dental health clinicians began serving in 26 state service programs in 14 states from 2011 to 2018. Survey responses were received from 455 administrators reporting on 754 of 1380 clinicians (54.6%). OUTCOME MEASURES: Administrators' ratings of their sites' difficulty recruiting clinicians; relative ease, quickness and cost of recruiting the participating (index) clinician with the service program; program expected effects on participants' retention; participants' job performance. RESULTS: Most administrators (66.1%) reported that recruiting clinicians of the index clinician's discipline is generally difficult but made easier (81.7%) and quicker (65.4%) with the service program, but only sometimes less expensive (34.8%). 78.8% of administrators anticipate that the clinicians will remain longer because of program participation. Participants are perceived to practice good quality care (96.9%) and be positive contributors (92.4%). Administrators' assessments are generally similar for the 3 types of programs. CONCLUSIONS: Administrators of safety net practices generally perceive states' loan repayment and loan forgiveness programs succeed in helping them recruit and retain good clinicians.

Editorial introductions

Editorial introductions

Editorial introductions.

Editorial introductions.

Incentive Programs for Physicians to Practice in Underserved Areas: A Nationwide Snapshot.

Access to health care is limited in part by maldistribution of physicians. Physicians agreeing to work in underserved areas can receive a financial incentive or a visa waiver that eases immigration restrictions. However, the overall landscape and scale of incentive programs and providers remains unelucidated. This article aggregates the reported output of state and federal programs and assesses their relative contributions to increasing the physician workforce in underserved areas. The estimates derived suggest that in 2017 the National Health Service Corps supported placement of around 2000 physicians, fully state-funded financial incentive programs about 1000, and visa waiver programs over 3500.