Certain elements of the medical military commitment requirements are similar to the service obligation requirements facing clinicians in NHSC’s Loan Repayment Program and Scholarship Program. Characteristics of the military medical program that are unlike NHSC requirements include:
Long obligation to repay subsidized medical training;
Military retirement eligibility only occurs after 20 years of service; and
Availability of physician retention bonus payments set by the military, based on medical specialty.
The accession and retention of military physicians is an integral part of maintaining an effective and sufficient medical workforce, particularly during periods of frequent deployments overseas. Currently, physicians enter the Army, Navy, and Air Force through one of four primary channels: the Uniformed Services University of the Health Sciences (USUHS), the Health Professions Scholarship Program (HPSP), the Financial Assistance Program (FAP), and direct commissioning of fully trained physicians (Edgar, 2009).
Retention among military physicians generally refers to an extension of the physician’s active duty service commitment after their initial service commitment has expired. All else equal, retention of skilled physicians is more cost-effective than recruiting and training new physicians. Because the skill-to-cost ratio is higher for retention than it is for recruitment, it makes sense to focus on retention efforts. The significant time lag between an individual’s commitment to serve and the actual provision of services further emphasizes the importance of reducing attrition of clinicians whose service commitments are about to expire.
Several studies evaluated the efficacy of current retention efforts in the Air Force Medical Corps and in the military at-large. For example, Keating et al. (2009) has shown that in virtually every accession category in the Air Force Medical Corps, the majority of entering physicians do not stay beyond their minimum service requirement.18 In 2009, the Senate Armed Services Committee (SASC) issued a directive to the Department of Defense (DOD) to evaluate medical workforce planning efforts, assess the existence of gaps between need and fill rate among certain specialties, and document challenges that contribute to clinician shortfalls. Retention was broadly defined as “retaining service members with the necessary skills and experience”
(GAO, 2009). For fiscal years 2001 through 2008, year-to-year medical personnel retention rates in the military’s eight branches ranged between 77 percent and 95 percent (GAO, 2009). The retention rate was calculated by first subtracting the number of medical officers who left service in a given fiscal year from the beginning total for that fiscal year. The difference was then divided by the total number of medical officers serving at the beginning of the fiscal year (GAO, 2009). Within this time frame, annual retention rate among active component military nurses was higher than that of military physicians and military dentists (GAO, 2009). Three main factors are cited as likely to affect retention: the pay differential between military and civilian physician positions; length of deployment; and opportunities for military physicians to maintain and improve clinical skills (Mundell, 2010). Most evidence suggests that increasing salaries for military physicians would lead to increased physician retention. The Multiyear Specialty Pay (MSP) program allows eligible physicians and dentists to make two-, three-, or four-year commitments to additional service in exchange for supplementary annual payments. Increasing MSP levels among Air Force physicians also increases the percentage of physicians who choose to accept contract renewal payments rather than leave service (Keating et al., 2009).
An analysis of dentist retention by Keating et al. (2009) found that between 1976 and 2007over 60 percent of dentists entering the Corps at the beginning of the study period stayed for longer than three years, while more than 40 percent stayed longer than seven years, and over 20 percent stayed longer than 19 years. However, retention over the study period fell across all experience levels. Additionally, while direct accession was the primary supply of dentists during the beginning of the study period, this trend eventually reversed, allowing HPSP graduates to become the most common accession source. While the cause for the decline in retention is not certain, factors differentiating Dental Corps participants and Medical Corps participants abound. Dentists inherently have fewer specialties from which to choose, and the promotion trajectory for dentists is much more predictable. Interestingly, eligible dentists accept MSP nearly four times the rate that physicians accept it (52 percent and 13 percent, respectively). The study does not analyze nurse practitioners, registered nurses or physician assistants.
18 Includes direct accessions, and accession through the Health Professions Scholarship Program (HPSP) and Uniformed Services University of Health Sciences (USUHS) medical school.