Clinical Care Access to Care Quality of Care Search Policies & Programs

hints
Display All Policies & Programs

Higher education financial incentives for health professionals serving underserved areas

Health Factors: Access to Care
Decision Makers: Local Government State Government Federal Government Healthcare Professionals & Advocates Public Health Professionals & Advocates
Evidence Rating: Some Evidence
Population Reach: 20-49% of WI's population
Impact on Disparities: Likely to decrease disparities

Is this program or policy in use in your community? Tell us about it.

Description

Financial incentive programs offer scholarships and loans with service requirements, educational loans with a service option, and loan repayment or forgiveness programs to encourage health care providers to serve in regions that are rural, underserved, or Health Professional Shortage Areas (HPSA). Such incentives are available to various types of providers, including physicians, nurse practitioners, physician assistants, nurses, dentists, and mental health providers, but typically focus on primary care and family medicine practitioners (Geletko 2014).

Expected Beneficial Outcomes

Increased availability of health professionals in underserved areas
Increased access to care

Evidence of Effectiveness

There is some evidence that financial incentive programs increase the number of health care providers serving in underserved areas (Goodfellow 2016, Cochrane-Grobler 2015, Wilson 2009, Sempowski 2004, Opoku 2015, Daniels 2007). Additional evidence is needed to confirm effects and determine which incentives are most effective (Goodfellow 2016, Misfeldt 2014).

Participants in financial incentive programs are more likely to serve in underserved areas than non-participating peers (Cochrane-Grobler 2015, Barnighausen 2009b, Daniels 2007). On average, participants remain in underserved areas longer than non-participants (Cochrane-Grobler 2015, Barnighausen 2009b). However, providers may not always stay in rural or remote communities following their commitment (Misfeldt 2014).

Scholarships, loan repayments (Misfeldt 2014), and loan forgiveness programs appear to support recruitment of health care providers to underserved areas (Daniels 2007). Loan repayment programs also appear to increase the duration providers practice in these locations (Goodfellow 2016, Renner 2010, Opoku 2015). Financial incentives are more effective as part of multi-dimensional programs than incentives alone (Sempowski 2004, Misfeldt 2014), and incentive programs offered at the end of training may be more successful than those offered earlier (Barnighausen 2009b). Surveys suggest that competitive salaries, professional development, knowledgeable support staff, and professional support may increase the likelihood of provider retention in rural or underserved areas after the completion of service commitments (Scarbrough 2016).

Mid-level providers such as nurse practitioners (NPs), nurse midwives, and physician assistants are more likely to practice in rural areas than other health care professionals (Daniels 2007). Primary care NPs (Spetz 2016, DesRoches 2013) and family medicine NPs (Odell 2013) are also more likely to practice in rural or underserved areas than NPs with other specialties. Research suggests that providers who participate in financial incentive programs may have elected to practice in underserved areas even without incentives (Renner 2010, Barnighausen 2009b). In particular, rural background or origin is associated with the decision to practice and remain in rural communities (Cochrane-Grobler 2015, Crump 2015, Petrany 2013, Renner 2010, Wilson 2009, Daniels 2007).

Experts suggest that expanding financial incentives with service requirements to include general surgeons (Tierney 2017, Collins 2016), OB/GYN physicians, nurse midwives (Smulian 2016), and telehealth providers offering mental health care (Collins 2016) may increase access in rural and underserved communities. 

Implementation

United States

The National Health Service Corps (NHSC) provides up to $50,000 in loan repayment and scholarships for physicians, dentists, advance practice nurses (nurse practitioners, certified nurse midwives), physician assistants, dental hygienists, and mental health professionals who work for two years in a Tier 1 Health Professional Shortage Area (HPSA) (US DHHS-NHSC). NHSC's Students to Service Loan Repayment Program (S2S LRP) also provides up to $120,000 to fourth year medical students who commit to practice primary care in a HPSA for three years full-time or six years half-time (US DHHS-NHSC-S2S LRP).

A number of other entities provide loan repayment programs. The Health Resources and Services Administration (HRSA), for example, offers a Nursing Education Loan Repayment Program that repays 60% of qualified loan balances for two years of work at a critical shortage facility; for an optional third year, it will pay 25% of the original balance (HRSA-NELRP). The Indian Health Service’s Loan Repayment Program provides $20,000 per year for two years for a variety of providers and allied health professionals; the contract may be extended annually until the debt is paid (US DHHS-IHS).

State funded loan repayment programs may complement the NHSC federal program (US DHHS-NHSC, Pathman 2012a). States can also include other specialties in their loan repayment programs, for example, in North Carolina general surgeons practicing in HPSAs are eligible (Collins 2016).

Wisconsin

Wisconsin's Health Professions Loan Assistance Program provides up to $100,000 in loan assistance to health care professionals including physicians, psychiatrists, dentists, dental hygienists, physician assistants, nurse practitioners, and certified nurse midwives. The Hospital Assessment Supplementary Loan Assistance Program provides physicians with up to an additional $100,000 in assistance, depending on practice location (WORH-HPLAP).

Implementation Resources

ASHA-Student loan repayment - American Speech-Language-Hearing Association (ASHA). The ASHA Leader. Student loan repayment looms for new clinicians. 2015. Accessed on September 13, 2017
HRSA-NELRP - Health Resources and Services Administration (HRSA). Nursing education loan repayment program (NELRP). US Department of Health and Human Services (US DHHS). Accessed on September 13, 2017
RHIhub-Loan forgiveness 2014 - Rural Health Information Hub (RHIhub). Programs for loan repayment and forgiveness: A list for rural providers. The Rural Monitor. 2014. Accessed on September 13, 2017
RTT Collaborative - RTT Collaborative. Rural education & training: resources on rural residencies, training tracks, program locations, and financial resources. Accessed on September 13, 2017
US DHHS-IHS - US Department of Health and Human Services (US DHHS). Indian Health Service (IHS). IHS Loan repayment program. Accessed on September 13, 2017
US DHHS-NHSC - US Department of Health and Human Services (US DHHS). National Health Service Corps (NHSC). Growing the primary care workforce by serving communities. Accessed on September 13, 2017

Citations - Description

Geletko 2014 - Geletko KW, Brooks RG, Hunt A, Beitsch LM. State scholarship and loan forgiveness programs in the United States: Forgotten driver of access to health care in underserved areas. Health. 2014;6(15):1994–2003. Accessed on September 13, 2017

Citations - Evidence

Barnighausen 2009b - Bärnighausen T, Bloom DE. Financial incentives for return of service in underserved areas: A systematic review. BMC Health Services Research. 2009;9:86. Accessed on September 13, 2017
Cochrane-Grobler 2015* - Grobler L, Marais BJ, Mabunda S. Interventions for increasing the proportion of health professionals practising in rural and other underserved areas. Cochrane Database of Systematic Reviews. 2015;(6):CD005314. Accessed on September 13, 2017
Collins 2016 - Collins C. Challenges of recruitment and retention in rural areas. North Carolina Medical Journal. 2016;77(2):99-101. Accessed on September 26, 2017
Crump 2015* - Crump WJ, Fricker RS, Ziegler CH, Wiegman DL. Increasing the rural physician workforce: A potential role for small rural medical school campuses. The Journal of Rural Health. 2015;00:1–6. Accessed on September 13, 2017
Daniels 2007* - Daniels ZM, Vanleit BJ, Skipper BJ, Sanders ML, Rhyne RL. Factors in recruiting and retaining health professionals for rural practice. Journal of Rural Health. 2007;23(1):62–71 Accessed on September 13, 2017
DesRoches 2013* - DesRoches CM, Gaudet J, Perloff J, et al. Using Medicare data to assess nurse practitioner-provided care. Nursing Outlook. 2013;61(6):400–407. Accessed on March 13, 2017
Goodfellow 2016 - Goodfellow A, Ulloa JG, Dowling PT, et al. Predictors of primary care physician practice location in underserved urban and rural areas in the United States: A systematic literature review. Academic Medicine. 2016;91(9):1313-1321. Accessed on September 26, 2017
Misfeldt 2014* - Misfeldt R, Linder J, Lait J, et al. Incentives for improving human resource outcomes in health care: Overview of reviews. Journal of Health Services Research & Policy. 2014;19(1):52–61. Accessed on September 13, 2017
Odell 2013* - Odell E, Kippenbrock T, Buron W, Narcisse MR. Gaps in the primary care of rural and underserved populations: The impact of nurse practitioners in four Mississippi Delta states. Journal of the American Association of Nurse Practitioners. 2013;25(12):659–666. Accessed on March 13, 2017
Opoku 2015* - Opoku ST, Apenteng BA, Lin G, et al. A comparison of the J-1 Visa waiver and loan repayment programs in the recruitment and retention of physicians in rural Nebraska. The Journal of Rural Health. 2015;31(3):300–309. Accessed on September 13, 2017
Petrany 2013* - Petrany SM, Gress T. Comparison of academic and practice outcomes of rural and traditional track graduates of a family medicine residency program. Academic Medicine. 2013;88(6):819–823. Accessed on September 13, 2017
Renner 2010 - Renner DM, Westfall JM, Wilroy LA, Ginde AA. The influence of loan repayment on rural healthcare provider recruitment and retention in Colorado. Rural and Remote Health. 2010;10(4):1605. Accessed on September 13, 2017
Scarbrough 2016* - Scarbrough AW, Moore M, Shelton SR, Knox RJ. Improving primary care retention in medically underserved areas: What’s a clinic to do? The Health Care Manager. 2016;35(4):368-372. Accessed on September 26, 2017
Sempowski 2004 - Sempowski IP. Effectiveness of financial incentives in exchange for rural and underserviced area return-of-service commitments: Systematic review of the literature. Canadian Journal of Rural Medicine. 2004;9(2):82–8. Accessed on September 13, 2017
Smulian 2016 - Smulian EA, Zahedi L, Hurvitz J, et al. Obstetric provider trainees in Georgia: Characteristics and attitudes about practice in obstetric provider shortage areas. Maternal and Child Health Journal. 2016;20(7):1341-1348. Accessed on September 26, 2017
Spetz 2016* - Spetz J, Skillman SM, Andrilla CHA. Nurse practitioner autonomy and satisfaction in rural settings. Medical Care Research and Review. 1077558716629584. Accessed on March 13, 2017
Tierney 2017* - Tierney J, Terhune K. Expanding the National Health Service Corps scholarship program to general surgery: A proposal to address the national shortage of general surgeons in the United States. JAMA Surgery. 2017;152(4):315-316. Accessed on September 26, 2017
Wilson 2009 - Wilson NW, Couper ID, De Vries E, et al. A critical review of interventions to redress the inequitable distribution of healthcare professionals to rural and remote areas. Rural and Remote Health. 2009;9(2):1060. Accessed on September 13, 2017

Citations - Implementation

Collins 2016 - Collins C. Challenges of recruitment and retention in rural areas. North Carolina Medical Journal. 2016;77(2):99-101. Accessed on September 26, 2017
HRSA-NELRP - Health Resources and Services Administration (HRSA). Nursing education loan repayment program (NELRP). US Department of Health and Human Services (US DHHS). Accessed on September 13, 2017
Pathman 2012a* - Pathman DE, Morgan JC, Konrad TR, Goldberg L. States’ experiences with loan repayment programs for health care professionals in a time of state budget cuts and NHSC expansion. The Journal of Rural Health. 2012;28(4):408–415. Accessed on September 13, 2017
US DHHS-IHS - US Department of Health and Human Services (US DHHS). Indian Health Service (IHS). IHS Loan repayment program. Accessed on September 13, 2017
US DHHS-NHSC - US Department of Health and Human Services (US DHHS). National Health Service Corps (NHSC). Growing the primary care workforce by serving communities. Accessed on September 13, 2017
US DHHS-NHSC-S2S LRP - US Department of Health and Human Services (US DHHS), National Health Service Corps (NHSC). Students to Service Loan Repayment Program (S2S LRP). Accessed on September 13, 2017
WORH-HPLAP - Wisconsin Office of Rural Health (WORH). Health professions loan assistance program information (HPLAP). Accessed on September 13, 2017

Page Last Updated

September 26, 2017

* Journal subscription may be required for access.