Health reform's primary care recruits: the National Health Service Corps
■ Paying more doctors to work in shortage areas is one plan for mending the nation's safety net before increased demand breaks it.
Jeanenne Brignac, MD, is exactly the type of physician the National Health Service Corps is looking for.
Dr. Brignac is a family physician and the only full-time doctor for roughly 20 miles around Pierre Part, La., a town of a few thousand people 40 miles south of Baton Rouge. The federal NHSC is repaying $50,000 of her $135,000 in student loans in exchange for working two years in an area short on health professionals. She is at a federally qualified health center with a nurse practitioner.
For Dr. Brignac, the opportunity was a perfect fit. She wanted to work in a small town in southern Louisiana even though she completed her residency at a Shreveport, La., hospital and has family in Baton Rouge. She was attracted to Pierre Part because many older people still speak Cajun, which is increasingly rare. She also knew it would be easier in a small town to develop close relationships with patients, who sometimes sustain such unusual injuries as alligator bites.
"I've got whole families that I take care of," she said. "I know the patients' mom. I know their siblings. I know their kids." Although she is contracted to work there until September, she plans to stay longer.
For years, the NHSC has been limited in scope and unable to meet the total need for primary care physicians and other health professionals in medically underserved areas. More want to help -- the program sometimes receives as many as seven applications for every available NHSC award.
That situation is changing. Thanks to $1.5 billion in support from the health system reform law and an additional $300 million from the 2009 economic stimulus package, the program is budgeted to provide more than five times as many loan repayment awards and scholarships in fiscal 2011 -- about 4,200 -- as it did in fiscal 2009. The additional health reform money will last through 2015.
For the first time, NHSC loan repayment awardees will be able to complete their service obligations by working part time and teaching medical students. So far, about 10% of 2011 cycle applicants have asked to serve part time, said Michelle Daniels, a spokeswoman for the Health Resources and Services Administration, which runs the NHSC.
The NHSC expansion is a key provision in the health reform law designed to attract more medical students and graduates into primary care. An estimated 32 million people are expected to gain health coverage beginning in 2014 under reform, but experts agree that not nearly enough primary care doctors are available to meet the demand.
Health and Human Services Secretary Kathleen Sebelius said physician training programs such as the NHSC are a priority of the Obama administration, as is getting preventive care to as many Americans as possible.
"Suffice to say we need more primary care doctors," she said. "We're trying to look at the levers throughout the department that we can use to help put some incentives in place."
The National Health Service Corps was created in 1970 to bring health professionals to areas of the U.S. that needed them. More than 37,000 clinicians have served since 1972. About 7,500 are serving now, 1,900 of whom are physicians, according to HRSA.
The NHSC has two types of financial awards: loan repayment for medical school graduates and scholarships with monthly stipends for medical students. Most members receive loan repayment.
NHSC clinicians must work in a health professional shortage area designated by the HHS secretary. One requirement is for an area to have at least 3,000 people for every practicing primary care doctor, in contrast to the normal ratio of one physician per 2,000 people.
Although the NHSC might be best known for placing primary care clinicians in underserved rural areas, slightly more physicians end up serving in urban areas with shortages.
The primary care shortage is so acute that NHSC clinicians have many choices of where they can serve. As of mid-January, there were more than 6,300 primary care health professionals shortage areas covering 38 million medically underserved people. Filling that need would require more than 17,000 primary care clinicians, according to HRSA.
Keeping doctors where they land
HRSA doesn't track the number of NHSC participants who continue to work at their sites once their service contracts are fulfilled. But in an August 2010 agency survey, three out of four NHSC participants said they planned to do so.
The NHSC is "a tremendous tool to recruit and retain providers," said Gary Wiltz, MD. He is the CEO of Teche Action Clinics in Louisiana, the network of seven health centers that employs Dr. Brignac in Pierre Part.
Dr. Wiltz, an internist, is one example of a successful long-term NHSC placement. He received a three-year NHSC scholarship to serve as the only physician at Teche Action's first health center in Franklin, La., a town of about 8,000. He's been there ever since his service was up in 1985.
Dr. Wiltz had planned to return to work in his hometown of New Orleans, about 100 miles northeast of Franklin. "About halfway through my obligated time, I realized this was what I was intended to do," he said. "It was so fulfilling. The people in these small rural communities are so grateful and appreciative."
Physicians said the loan repayment and scholarships have helped many young primary care doctors survive financially. But those who decided to stay after their contract expired -- or who plan to -- share a love of serving the needy in the particular place they ended up.
Rogelio Fernandez, MD, began working at United Health Centers in rural Fresno County, Calif., in 1991 under a two-year NHSC contract. He always wanted to work with farmworkers' families, having been in one himself. "The loan repayment was kind of a bonus," he said. Now he's the associate medical officer of the chain's health center in Parlier, Calif., about 20 miles southeast of Fresno.
Sherell Mason, MD, remembers growing up uninsured in west Baltimore and getting treated at community health centers. "As a patient, you kind of felt like you were being shuttled along a long train of people without a lot of regard," she said. "I remember as a kid feeling sort of like a number." Dr. Mason tries to offer stronger relationships with patients as the associate medical director for Total Health Care, which has nine health centers in Baltimore.
The hardships of the job
Bernard Abbott, MD, a pediatrician and chief medical officer at the South Baltimore Family Health Center, began working at the center in 1983 to pay back an NHSC scholarship. He's been at the same center ever since.
Dr. Abbott said the number of NHSC awardees seeking jobs at his health center has increased in recent years. Many physicians want to work in cities such as Baltimore, which offer the support of large hospitals and health systems that don't exist in many rural areas.
However, he has been hiring fewer NHSC participants than he was several years ago. Although he believes firmly in the program, he knows awardees are more likely to move on than to stay long-term at a health center, in part because of the relatively low pay.
The desires of physicians' spouses and families also are important influences, said Dr. Wiltz of Louisiana. For instance, some female physicians who wanted to start families ruled out serving in the NHSC because of the previous full-time work requirement, he said.
For those who choose to serve in a rural location, the isolation can be overwhelming. Dr. Brignac says she likes knowing her patients on a more personal level, but that means she can't really clock out. She often must deal with her patients' mental health issues on top of their chronic health problems. And local patients don't like to travel out of town, which means they rely on Dr. Brignac for virtually all their health care.
"In primary care like this, you constantly have people calling," Dr. Brignac said. "I do take stuff home all the time."
Working in an underserved urban location has its own challenges. Some patients have some of the same psychiatric issues -- plus substance abuse problems, said Jeffrey Lester, MD, an internist working at Family Health Centers of Baltimore in an NHSC placement. Getting specialists for his patients also can be difficult, he said.
The pressures could test physicians who want higher pay and more regular hours. But those who drop out of the NHSC in the middle of a contract face severe federal penalties.
Ronald Yee, MD, has had some success retaining NHSC physicians at Fresno County's United Health Centers, where he is chief medical officer. He tries to find work that matches the interests of the doctors. Dr. Yee also offers additional training and encourages medical staff to connect more with the community.
Dr. Wiltz and Dr. Yee are among the physicians who for years have advocated for more flexibility in fulfilling NHSC service. In the mid-1990s, Dr. Wiltz chaired a federal panel recommending that participants be able to work part time and teach, a request that health reform finally granted 15 years later.
HRSA expects to begin accepting the next round of National Health Service Corps scholarship applications in April. The agency hopes the effort will result in a new wave of primary care doctors who will help strengthen the safety net in the areas needing it the most -- and stay there.
Physicians such as Dr. Mason in west Baltimore are already there. "I think I'm here for the long term. I'm very happy."