Federal Loan Repayment Alleviating Severe Clinician Shortages

Providers practicing in areas with the most severe clinician services are receiving more workforce funding through National Health Service Corps (NHSC) programs that offer either loan repayment or scholarships, the Government Accountability Office (GAO) reports.

About one-quarter of the US population lives in an area with a shortage of clinicians. The government identifies areas with the least number of clinicians per population, among other factors, and gives the so-called health professional shortage area (HPSA) a score between 1 to 25. A higher score indicates a more severe shortage of primary care or mental health providers.

NHSC programs aim to alleviate clinician shortages by offering scholarships and loan repayment to providers in exchange for delivering primary, dental, or mental health care at certain clinical sites located in HPSAs.

In fiscal year (FY) 2020, over 14,000 providers served as part of an NHSC program, GAO reported. And of those providers, most of the providers served in sites in relatively more severe clinician shortage areas, with an HPSA score between 16 and 21.

Three of the five NHSC programs also prioritized awards to providers serving at sites with higher HPSA scores, according to the report.

Additionally, NHSC’s largest program, the General Loan Repayment Program, denied funding to 959 applicants in 2020 because they worked in a relatively less severe clinician shortage area with a lower HPSA score, rather than because their applications were incomplete or ineligible. Notably, 40 percent of these applicants were still practicing at sites with HPSA scores that were in the upper half of possible scores.

“If additional NHSC funding was available, these applications would be the next to receive reviews by HRSA and potentially receive funding, according to HRSA’s guidance,” GAO stated.

NHSC programs appear to be achieving their goal of alleviating clinician shortages to ensure access to care for patients. In fact, NHSC providers practiced in every state, the District of Columbia, and five US territories. About 44 percent of participating sites were in rural areas.

Rural areas have especially faced significant clinician shortages, with a 2020 study confirming urban-rural disparities primary care workforce disparities. Longer travel distances to access care have largely contributed to primary care clinician shortages.

GAO also found that about 60 percent of NHSC providers serviced at federally qualified health centers (FQHCs) in FY 2020, followed by community mental health centers, community outpatient facilities, and American Indian and Alaska Native health facilities.

More primary care providers worked at FQHCs that year. But the most common disciplines overall were nurse practitioners (26 percent), physicians (15 percent), and licensed clinical social workers (12 percent), GAO found.

Still, about 5 percent of participating sites had vacancies. The vacancies were most common in FQHCs and the largest proportion of vacancies were among sites with the highest HPSA scores.

More NHSC sites with vacancies (33 percent) were seeking primary care providers, followed by licensed clinical social workers (14 percent) and licensed professional counselors (10 percent).

Studies conducted by the Health Resources and Services Administration (HRSA), which runs NHSC programs, found that satisfaction is high among providers in the General Loan Repayment Program and NHSC providers increased healthcare capacity for community health centers.

Provider retention was also high in HPSAs after clinicians completed their service per program rules. Of over 19,000 providers who completed their service between 2012 and 2019, about 80 percent still worked in a HPSA as of October 2020, HRSA officials told GAO.

“HRSA officials also said that that the agency has ongoing efforts to determine if applicants who received NHSC funding are more likely to continue to practice in HPSAs than applicants who did not receive funding, which may indicate the effect of receiving NHSC funding on providers’ choice of practice location,” GAO wrote in the report.

Incenting providers to practice in clinician shortage areas is a top priority for improving access to care, especially stepping out of a global pandemic.

“The physician workforce shortages that our nation is facing are being felt even more acutely as we mobilize on the front lines to combat the COVID-19 national emergency,” David J. Skorton, MD, president and CEO of the Association of American Medical Colleges (AAMC), said last year. “The increasing physician shortage over the last two decades, and now the COVID-19 pandemic, has demonstrated that we need to increase the number of physicians to ensure we can care for patients in the near-term and in the future.”

AAMC estimates the physician shortage to be between 54,100 and 139,000 physicians by 2033. The estimates were taken before COVID-19 hit, but the pandemic “magnifies the need to address shortfalls in both primary care doctors and specialists,” according to AAMC.

Just recently, the American Hospital Association (AHA) called on Congress to consider more funding for healthcare professional education and workforce programs.

“A qualified, engaged, diverse workforce is the core infrastructure of our health care system,” AHA wrote in an April 2021 letter to Congress members. “Yet COVID-19 has taken a heavy toll on our health care heroes who have been on the front lines of the pandemic with many suffering from trauma, burnout and increased behavioral health challenges.”

“Additionally, we are increasingly hearing that practitioners are choosing to retire early, given the strain of the past year. Congress should support efforts to ensure an adequate, sustainable [healthcare] workforce,” the letter continued.