The Armed Services currently offer a variety of incentive plans to bolster retention, including accession bonuses and other pay incentives, scholarship programs, special pays, loan repayment programs, and retention bonuses. Findings from evaluations of these programs may inform our understanding of retention in analogous programs in NHSC.
An evaluation of the Multiyear Specialty Program (MSP) was commissioned by the Air Force in 2009 to assess the tendencies of physicians and dentists in the Air Force Medical Corps and Dental Corps to accept MSP. The study (Keating et al., 2009) differentiates between retention among two cohorts of MSP eligibility. The first “peak” of eligibility occurs after three or four years, when physicians who completed a civilian residency fulfill their initial service obligation (termed ‘early eligibles’). The second eligibility peak occurs after seven to eight years, when military residency-completing physicians fulfill their initial service term (‘later eligibles’). ‘Later eligibles’ accept MSP at much higher rates than ‘early eligible’ physicians.
Several findings from this study are consistent with other evidence suggesting that prior indication of commitment to serving a particular population or organization is correlated with longer retention. Although retention in the Air Force Medical Corps is overall low, retention among USUHS graduates is notably high. Graduates were just as likely to stay for over 20 years as they were to leave after serving their minimum service obligation. It is suggested that members of this group, in particular, have a greater inclination for military service. For recipients of the Health Professions Scholarship program, the largest accession group, completing a military residency was associated with nearly a three-fold increase in the likelihood of remaining for more than 20 years, relative to those who completed a civilian residency. One hypothesis is that a military residency is indicative of greater commitment to military service and/or, the military residency allowed physicians additional time to become acclimated to military culture (Keating et al., 2009).
Overall, accession source and whether the physician completed a military residency (for HPSP entrants) were the factors most strongly associated with retention in the Air Force Medical Corps. Short-term retention (retention within the first seven years of entrance) for HPSP entrants and long-term retention (20 years or longer) has not changed consistently or considerably between entering cohorts from 1979 to 2000. Within this time period, short-term retention for HPSP entrants with military residencies was approximately 55 percent of all entrants and 5-15 percent for physicians with civilian residencies. Long-term retention was 12-18 percent for scholarship program entrants who completed military residencies, compared to 3-8 percent for those who completed civilian residencies.
Recent research by Gray et al. (2012) found that military retention is highly sensitive to civilian-military compensation differences in the first year of obligated service and substantially less sensitive after the initial year. Gray et al. (2012) found that a 10 percent increase in total compensation is associated with an approximate 18.7 percent increase in retention during the first unobligated year, but just a 0.2 percent average increase in yearly retention thereafter, up to the point of retirement eligibility at 20 years of service. Further, while studies have demonstrated the effect of deployment length on retention, little research has been performed on deployment length, which can vary significantly among practitioners and may impact morale and how clinicians view their deployment tours (Edgar, 2009). Administrative burden is also commonly cited as a major deterrent, particularly regarding the Armed Forces Health Longitudinal Technology Application (AHLTA) electronic medical record system.
While the impact of pecuniary rewards on retention is relatively well documented, albeit variable, the link between the ability to maintain or improve clinical skills and retention is less well understood. In exchange for additional service, physicians may receive a MSP, a permanent change of station, or opportunities to pursue further training. Research has shown that physicians are more likely to stay in the Air Force Medical Corps when offered higher MSP levels (Keating et al., 2009). An earlier study by Daubert (1985) analyzed the retention of direct-accession physicians into the Air Force during 1980s and found the lack of parity between civilian and military wages and lack of professional development opportunities were key reasons for low retention.
Mundell (2010) estimated the magnitude of the effect of “practice opportunities,” on the retention of critical care specialists in the Army, Navy, and Air Force. Using data from the Defense Manpower Data Center, the study sought to determine the effects of practice opportunities (using facility type as proxy) on the military’s ability to retain physicians. The estimates, obtained from duration models, suggest that a hypothetical programmatic shift of assigning physicians to large medical centers between June 1996 and June 2009 would have led to an increase in average active duty duration of approximately 0.62 months across all three services (Army, Air Force, and Navy) in the first 5.5 years of post-residency service. Implementing a required military residency would have led to an increase of approximately 1.8 months across all three services in the first 5.5 years of post-residency service. Furthermore, the results suggest that increasing deployment length or frequency during a physician’s initial service obligation decreases retention, while increases in the same two dimensions after the clinician has completed the initial service term do not have a negative effect on retention and may even have a positive effect in certain cases. This is consistent with the hypothesis that those with a dis-preference for deployment leave after completing their initial obligation.22
22 Other findings for non-medical military personnel suggest a positive correlation between deployment and retention. Though longer deployment (beyond 11 months) has negative effects on retention, higher reenlistment bonuses have helped the Army retain its personnel in spite of longer deployment (Hosek and Martorell, 2009).