Provider Retention in High Need Areas. Appendix A: Previous Literature


In this appendix we provide an extensive literature survey focused on the retention metrics, policies and practices concerning NHSC programs. We also take into account literature providing estimates of the effects of other federal, state, or institutional programs on the number of NHSC providers.15 In essence, our review includes a discussion of the following components:

  • Designations of Health Professional Shortage Areas (HPSA) and other definitions for underserved areas

  • Definitions of retention and retention metrics used for NHSC enrollees

  • Retention metrics used elsewhere in the health sector and in the military

  • Previous estimates of the effect of NHSC programs on recruiting and retention

  • NHSC enrollment and retention under the Patient Protection and Affordable Care Act (ACA) and American Recovery and Reinvestment Act (ARRA) funding expansion

  • Variation in health workforce retention in different health networks

  • Strategies to increase provider retention in underserved areas and the impact of these strategies

Our literature review indicates that clinician retention in the NHSC programs has been a frequently studied topic over the past several decades. Although there appears to be substantial variation in the definitions of retention, with respect to provider’s location after completion of the service obligation or time frame over which retention is assessed, all currently available empirical estimates suggest that retention is heavily influenced by a number of common factors. These factors include: being motivated primarily by the nature of the work rather than by financial incentives; having prior experience in an underserved area; or having educational and employment opportunities for other family members. Findings from analogous programs run by states, institutions, and the Armed Forces reach similar conclusions.

Overall, NHSC has had success in recruiting clinicians into both programs over the years, particularly following the supplemental funding from the 2009 American Recovery and Reinvestment Act (ARRA), which allowed NHSC to place practitioners at more service sites as well as extend many service contracts. Retaining these clinicians after they complete their service requirements is essential to the program’s lasting impact on communities of need. The program’s impact is essentially doubled when clinicians supported with an initial two-year loan repayment award choose to remain in their service sites for an additional two years beyond their service term (Pathman and Konrad, 2012). Clinicians who eventually leave their original service sites but continue serving at-risk populations at other sites also contribute to the NHSC’s goal of impacting underserved communities.

Results of a 2012 retention assessment survey conducted by NHSC show that over the past decade short-term and long-term retention rates, measured as the fraction of providers remaining for up to one year beyond service term and remaining for ten years beyond service term, respectively, have increased (National Health Services Corps, 2012). Short-term retention increased by 28 percent between the two iterations of the survey, conducted in 2000 and 2012. Over 82 percent of NHSC alumni continue to practice in underserved communities for up to a year after service completion, while 55 percent of alumni remain in these areas ten years after completing their service obligation. Long-term retention has increased by 6 percent between 2000 and 2012, and is markedly higher for those who served in rural communities.

15 The current literature review discusses the State Loan Repayment Program (SLRP), a grant program administered by HRSA providing costing-sharing grants to over 30 states for the purpose of operating state loan repayment programs for primary care clinicians working in Health Professional Shortage Areas (HPSAs). However, the analysis in this project does not attempt to determine how the SLRP directly affects NHSC retention, and does not evaluate potential spillover effects of the program.

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