Provider Retention in High Need Areas. Introduction


The National Health Service Corps (NHSC) is administered by the Bureau of Health Workforce (BHW) in the Health Resources and Services Administration (HRSA). The NHSC was originally designed to address geographic maldistribution of the health care workforce by increasing the number of health care professionals in areas designated by HRSA to be Health Professional Shortage Areas (HPSAs). Under Assistant Secretary for Planning and Evaluation (ASPE) leadership in coordination with HRSA, The Lewin Group is focusing on two programs within the NHSC: the Loan Repayment Program (LRP) and the Scholarship Program (SP). While the LRP has expanded significantly since 2009, the SP is constrained by budget policy. In FY 2014, individuals participating in LRP could receive up to $30,000 for a 2-year commitment in a HPSA with scores between 0 and 13 and up to $50,000 for a 2-year commitment in a HPSA with scoresof14 or higher. However, the statute allows for up to $35,000 per year (or $70,000 over two years). The Scholarship Program offers funding for a maximum of four years for: school tuition, required fees, education costs and a monthly support stipend. In exchange, SP participants agree to provide primary health care in a HPSA for a number of years that is equal to the number of years they were scholarship recipients.

The NHSC deploys almost 9,000 health care professionals to thousands of sites across the country annually (National Health Services Corps, 2012). In the FY 2015 Department of Health and Human Services (DHHS) budget, President Obama proposes boosting the National Health Services Corps to 15,000 a year over the next five years (DHHS Budget, 2014). These clinicians include primary care physicians, primary care certified nurse practitioners, certified nurse-midwives, primary care physician assistants, dentists, registered dental hygienists, health service psychologists, licensed clinical social workers, psychiatric nurse specialists, marriage and family therapists, and licensed professional counselors. These professionals deliver critical medical, dental, and mental health services in geographic areas, facilities, and populations that have limited access to health care services (Health Resources and Services Administration, 2013). In exchange for a service commitment (typically 2-5 years) the NHSC provides students with medical education incentives through the LRP and SP programs. Upon the conclusion of an initial service obligation period, NHSC providers may apply for additional loan repayment funding in return for further service.

In September 2013, ASPE awarded The Lewin Group a contract to examine short- and long-term retention in high-need areas of providers who participated in the LRP and SP programs and compare their retention with retention of non-participants working in those areas. Important questions for ASPE and HRSA is how many providers who participate in the NHSC loan repayment and scholarship programs remain in high need areas once they have completed their contract obligations and how their retention compares with the retention of providers in high need areas who did not participate in the program. This study addresses these questions using data from the period 2000-2013. Several past studies have addressed these questions, but with now often dated data obtained mostly by small scale surveys that have focused almost exclusively on physicians. In addition to physicians, this study will examine retention of non-physician providers, including nurse practitioners, physician assistants, mental health and dental care clinicians.

We start with a detailed survey of the literature about the NHSC program, including studies of how participant retention in high-needs areas compares with non-participant retention. Next, our empirical approach encompasses various data methods to evaluate the retention of NHSC providers beyond their initial service obligation. We utilize several large-scale administrative databases to track providers over time and compare the NHSC participant retention with the retention of comparable non-NHSC providers in the same HPSAs. In this document we produce detailed statistics on the number of years providers remain in the same HPSA after completion of their initial contract, whether they locate in a different HPSA, whether they remain in the same area but outside of HPSAs, and whether and when they move to other geographical areas (HPSAs or non-HPSAs). These statistics are broken down by provider type, age and other relevant characteristics. Next, we compare these trends with the retention and migration trends of non-NHSC providers that have similar characteristics and who at some point serve in the same HPSAs as the NHSC participants.2

In this study we also specify a formal economic model of individual geographic location decisions and apply that model to the NHSC programs, with an emphasis on the LRP. The model isolates the key factors influencing geographic location decisions, and it explains why some individuals might choose to locate in areas that others avoid. The model also explains when geographic mobility will be high and when it will be low. The general model of location decisions is modified to account for the essential features of the NHSC program. In particular, we show that the retention of participants in high-need areas after they complete their obligations depends crucially on the way that NHSC selects participants into the program.

To measure this relationship between enrollment, retention and monetary value of the NHSC programs we conduct econometric analyses to estimate the effect of LRP and SP on enrollment in the NHSC workforce and retention of participants in health care shortage areas. In these analyses we attempt to control for individual socio-demographic characteristics as well as for the multiple unobservable factors that are associated with the individual provider’s decisions to: enroll in NHSC; continue with NHSC under a new contract; stay in the same location after NHSC service completion; move to another HPSA after service completion; or move to a non-HPSA after service completion. Some of these unobservable characteristics are the preference for serving in rural/underserved areas, financial constraints or factors that may make a provider more likely to prefer to work in a certain location regardless of participation in NHSC programs (e.g., being close to one’s place of birth).

Although NHSC continues to achieve gains in the recruitment and retention of clinicians, further progress may be desirable. Today, 21 percent of the nation’s population resides in 5,800 Federally-designated shortage areas, and this proportion is climbing (NCSL, 2011; HRSA, 2013). Shortages of primary care services in underserved areas are likely to be further exacerbated, with the Affordable Care Act (ACA) coverage expansion expected to affect underserved areas disproportionally. While rural communities do not necessarily equate to underserved areas, the discrepancy between clinician need and supply in rural areas is sizeable—nearly 21 percent of the US population resides in rural areas, but only 9 percent of the physician workforce practices in such settings (Health Resources and Services Administration, 2011(a)).

A detailed survey of the existing literature relating to the NHSC scholarship and loan repayment programs is contained in Appendix A. The main body of the report is organized as follows. Chapter II provides a detailed discussion of our data sources and main measures. Chapter III presents summary statistics obtained with these data sources, including measures of the retention and geographic mobility of NHSC participants and non-participants. Chapter IV develops an economic model of location choices and uses that model to derive predictions about how the retention of NHSC participants in high-need areas will compare with the retention of non-participants. Chapter V uses the data to derive estimates of retention differences between participants and non-participants that control for a host of observable factors, including the provider’s medical discipline, age and gender as well as other factors such as local area median income and percentage of the population in poverty. Finally, Chapter VI simulates the economic model constructed in Chapter IV under different assumptions about the key parameters in the model. The empirical findings are interpreted in light of these simulations. Chapter VII concludes the report.

2Holmes (2005) pointed out that relating NHSC participation to HPSA designation may pose some problems, as, for instance, the areas that may be most underserved may not apply for HPSA status. An alternative approach would be to explore the enrollment and retention of NHSC providers in areas where the provider to patient ratios indicate shortages of primary care providers. However, this is beyond the scope of the current study.


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