The archiving and publishing of the proceedings of the introductory remarks and the first two plenary sessions of the First National Conference on Primary Health Care Access (April 20, 1990) was made possible, in part, through the generous support of the Michigan State University/Sparrow Hospital Family Medicine Residency Program, Lansing.
Donald L. Weaver, MD, Director, National Health Service Corps: The National Health Service Corps (NHSC) was formed by the Emergency Health Personnel Act of 1970 (PL 91-623), to address the maldistribution of health personnel in the United States. Through the placement of Health professionals in underserved areas, access to primary care services would be improved; removing geographic, financial, language, and cultural barriers.
The history of how this legislation was developed and signed into law is recorded in a fascinating book, The Dance of Legislation, by Eric Redman. Supported by Representative Paul Rogers from Florida and Senator Warren Magnuson from the State of Washington, the NHSC was signed into law on December 31, 1970.
The mission of the National Health Service Corps is to provide health professionals to those communities and populations of greatest need which cannot otherwise recruit and retain health care providers. To be eligible for NHSC personnel, an area or population must be federally designated as a Health Manpower Shortage Area (HMSA).
An HMSA is a rational service area with a physician to population ratio of 1:3500 (or 1:3000 if there are indicators of unusually high need, such as high levels of poverty or high infant mortality). Within a given HMSA, a community-based system of care is then sought to be the setting for a NHSC practice.
In January 1972, the initial 17 health care professionals were placed by the NHSC, with the number of NHSC members providing care to the underserved in a given year peaking at over 3,000 in 1986. Originally, an all volunteer service, the NHSC Act was amended in 1972 by PL 92-585 and in 1976 by PL 94-984 to include a scholarship component. While the volunteer component of the NHSC continued, the scholarship program grew and became an integral part of the activities of the NHSC.
Since 1974, there have been over 13,000 individuals who have received scholarships from the NHSC. Approximately 83 percent of the scholarship recipients fulfilled their obligation through service and approximately 13 percent elected to fulfill their obligation through repayment. Although the law allows repayment as an option, the goal of the NHSC is to have as many individuals as possible fulfill their obligation through service to the underserved.
Over the last five years, the number of NHSC scholarship recipients available for service has markedly diminished. The decrease was a direct result of the lack of appropriations for the program in the early 1980’s. The appropriation reduction was in part the result of Graduate Medical Educational Advisory Council (GMENAC) and other studies indicating that there would soon be a surplus of physicians in the country, and that everyone would be within 25 miles of a primary care provider.
It was felt by many that “diffusion” (market forces) would result in physicians moving into the less desirable rural and urban inner city practices. Given these predictions and concerns about the budget, the scholarship program underwent considerable reductions until there were no appropriations for scholarships in the early 1980’s.
Many felt that the scholarship program had the disadvantage of asking students to make a commitment to a primary care career too early in the educational process. Some students would incur an obligation to serve the underserved as a primary care provider and then decide to pursue a career in a non-primary care specialty.
In addition, there was increasing recognition that despite the predictions of a physician surplus, the problem of individuals lacking access to primary health care services continued. With the passage of Public Law 100-177 in 1987, modest funding was made available for a Federal Loan Repayment (FLR) and a State Loan Repayment (SLR) program.
The loan repayment programs have the advantage of selecting individuals for participation who are completing or have completed their training and, therefore, have already made a commitment to primary care. Both the FLR program and the SLR program, in their infancy, have had some degree of success in getting providers to locate in underserved areas.
Since individuals in the FLR/SLR programs are volunteers until they match to a site, they have the option of saying no to serving in the hardest-to-fill underserved areas. The scholarship program has had greater success in getting providers to serve in the hardest-to-fill- underserved areas. The scholarship program has also helped to target disadvantaged individuals who could choose to pursue a primary care health professional career without the prospect of a tremendous loan debt upon completion of their education.
Given the complementary nature of the scholarship and loan repayment programs, funds were identified which allowed 41 scholarships to be awarded in the Fall of 1989. To help identify the most appropriate applicants, an interview process was instituted. Potential scholars were evaluated on the following:
- Did the individual understand that this was a scholarship, not a loan? The NHSC expected service to the underserved as a return on the scholarship investment.
- The NHSC was looking for primary care physicians – family physicians, OB/GYNs, general internists, and general pediatricians. What commitment did the applicant have to pursuing a career in one of these specialties?
- Would the Applicant be comfortable in providing primary care in rural areas? This was not meant to imply that all assignments would e in rural America, However, 70 percent of the HMSAs are rural and most medical training programs: a) are located in urban or suburban areas (with individuals wanting to stay close to where they trained); and b) do a comparatively poor job of training physicians for rural practice.
- Was this an individual who would provide culturally sensitive health care? The interviewers were asked to look at the individual’s life experiences which might be an indicator of his or her commitment to serve the underserved as a primary care provider.
Just as there are several ways in which individuals are recruited into the NHSC, there are several ways in which providers are employed as NHSC field assignees. When the first individuals were placed by the NHSC in 1972, they were all federal employees. As federal employees, these individuals are covered under the Federal Tort Claims Act for malpractice, a significant savings to those systems of care which employ these individuals. This is of particular significance for individuals who are providing obstetrical care.
As the NHSC grew, the way sin which individuals could be employed to service the underserved expanded. The three additional ways in which an individual can receive compensation for serving the underserved through the NHSC are:
- Private practice option: a traditional fee-for-service practice.
- Private practice salary: a salary from an entity other than a federally funded community or migrant health center.
- Private practice assignment: a salary from a community or migrant health center.
The variety of payment mechanisms has served the NHSC well, allowing the program to use its budget to the fullest extent possible.
As the program expanded, the diversity of sites for placement expanded. Placements are made into financially viable systems of care, with the caveat that all individuals must be cared for without regard for their ability to pay. Initially, all NHSC placements were in rural areas. The NHSC now has practice opportunities in community-based systems of care in the neediest rural and urban areas.
Given the need for a critical mass of age-specific individuals to have a viable practice for OB/GYNs, pediatrics, and internists, the NHSC has recognized the unique ability of family physicians to care for the full range of individuals and has targeted these providers for rural America. This policy has permitted the NHSC to get maximum utilization of its scarce resources to assure that as many underserved populations as possible are served.
The success of the NHSC over the past 20 years in meeting the needs of the underserved is the result of practitioners who have made a commitment to dedicate part or all of their professional careers to helping those most in need. Some providers have remained in the community after serving with the NHSC while others have moved on to other practice opportunities.
Many serve the underserved in other community-based systems of care, pursue an academic career and influence health professionals in training to commit part or all of their careers to serving the underserved, or integrate serving the underserved into their private practice.
As recorded in The Dance of Legislation, many felt that physicians and other health professionals would go into underserved areas if they received help in getting a practice started. It was hoped that once this start up assistance was completed, these individuals would flourish in their practice and remain in the area. This would allow the NHSC to move into another community and set up other individuals in practice.
To be sure, there continues to be underserved areas where this scenario will work well, given a stable financial base in the community. But, there is an increasing realization that some other communities will remain NHSC sites for financial, geographic, and a variety of other reasons as long as there is an NHSC.
Unfortunately, diffusion did not occur as anticipated and the need to improve access to primary care services to the underserved has increased. The Council on Graduate Medical Education (COGME), created by Congress to make recommendations regarding current and future adequacies of physician supply, adopted as their first principle: “The primary concern of the Council must be the health of the American people. There must be assured access for all to quality health care.”
In COGME’s July 1988 report, it was stated that there “is now or soon will be an aggregate oversupply of physicians in the United States.”
COGME’s report also stated:
Conclusion B-1. There is a geographic maldistribution of physicians with too few physicians in many rural and inner city areas.
Conclusion C-1. Minorities are still underrepresented in the physician manpower pool in the United States
Conclusion D-2. There is an under-supply of physicians in family medicine.
These conclusions reinforce the need to have programs which focus on meeting the needs of the underserved. Using data available from the Office of Shortage designation, there are 1,955 primary care HMSAs that would need 4,224 physicians to meet the needs of the undeserved as of June, 1989.
Over the last 20 years, the mission of the NHSC has remained constant although there have been numerous strategies to meet the needs of the underserved. From an all volunteer organization, the NHSC has included a large scholarship component and the relatively new federal and state loan repayment programs.
From an all federal employee organization to expanded employment options, the NHSC has adapted to serve as many people as possible with the resources available. When over 1,600 scholars were available for placement in 1985, the major emphasis of the program was placement.
With the limited supply of available primary care providers, the major emphasis of the NHSC turned to retention and volunteer recruitment. The NHSC’s success has been highlighted by its ability to adapt to the resources available.
The charge for this conference was to list any limitations to meet the needs of the future. There are three potential limitations to the future of the NHSC:
The first limitation is funding. The funding for last year’s scholarships and loan repayment enabled the program to award 41 scholarships, approximately 100 FLR contracts, and approximately 120 SLR contracts
The second limitation is the need for an increased awareness of the fact that the dual goals of trying to place providers in the hardest-to-fill areas and trying to retain individuals in these areas will never coincide 100 percent. The NHSC can improve on its past record, but the factors, in many instances, are not inclusive.
The third limitation is the fact that the NHSC can only be as effective as the primary care providers that are available to provide service. Given the studies indicating waning interest in primary care specialties as a career choice, the NHSC will have to recruit an increasingly larger share of an increasingly smaller pot. That could be a real limitation to the program.
In the past 20 years, the NHSC has an outstanding record of helping to meet the needs of the underserved. There is now considerable interest within the Department of Health and Human Services and the Congress about a revitalized NHSC. According to Webster, “revitalize” means to “breathe new life or vigor.” Building on a proud past, the revitalized NHSC will continue to be a partner with other public and private organizations that share the common goal of helping meet the needs of the underserved.
(points of view opinions expressed in this presentation are those of the author and do not necessarily represent the official position or policies of the U.S. Department of Health and Human Services.)
Dr Weaver’s presentation was preceded by: First National Conference on Primary Health Care Access (1st Plenary Panel, Part 1, Schmidt)
Dr Weaver’s presentation was followed by: First National Conference on Primary Health Care Access (1st Plenary Panel, Part 3, Hullett)