National Health Service Corps:

Opportunities to Stretch Scarce Dollars and Improve Provider Placement

HEHS-96-28: Published: Nov 24, 1995. Publicly Released: Dec 4, 1995.

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Pursuant to a congressional request, GAO examined the National Health Service Corps (NHSC) scholarship and loan repayment programs, focusing on: (1) the programs' costs and benefits; and (2) whether NHSC has distributed available providers to as many eligible areas as possible.

GAO found that: (1) the loan repayment program costs less per year of obligated service, and loan recipients more often extend their service; (2) the scholarship program offers a better guarantee that providers will serve in the neediest shortage areas, since it gives recipients less freedom of choice in deciding where to serve; (3) scholarship recipients more often breach their contracts; (4) a provision allowing scholarship recipients to fulfill their obligations through research limits the program's effectiveness; (5) NHSC has allowed placement of more providers in an area than necessary to remove the area's shortage designation; (6) NHSC has trouble meeting needs in areas that request, but do not receive, NHSC providers, and in areas that face barriers to requesting providers; and (7) for 1996, NHSC intends to limit provider placements based on primary-care-physicians-to-population ratios, but will not consider the number of nonphysician providers in limiting placements.

Matters for Congressional Consideration

  1. Status: Closed - Implemented

    Comments: The Health Care Safety Net Amendments of 2002 (P.L. 107-251) amended section 338C of the Public Health Service Act by striking the section that allowed the option for NHSC scholarship recipients to fulfill the service obligation under the National Research Service Award.

    Matter: Congress should consider amending the Public Health Service Act to eliminate the option for NHSC scholarship recipients to fulfill the service obligation under the National Research Service Award.

  2. Status: Closed - Implemented

    Comments: The Health Care Safety Net Amendments of 2002 (P.L. 107-251) amended section 338H of the Public Health Service Act, authorizing the Secretary greater discretion to allocate larger amounts of NHSC funding through loan repayment awards (relative to the scholarship program) than previously allowed.

    Matter: Congress should consider amending the Public Health Service Act to direct the Secretary of Health and Human Services to use the loan repayment program rather than the scholarship program, to meet future NHSC needs, or authorize the Secretary greater discretion to allocate larger amounts of NHSC funding than currently allowed through loan repayment awards.

  3. Status: Closed - Not Implemented

    Comments: Congress has not taken action on this recommendation.

    Matter: Congress should consider amending the Public Health Service Act to eliminate any existing statutory barriers to the use of flexible work schedules for providers fulfilling their obligations.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: According to NHSC officials, NHSC now counts NHSC clinicians serving in the areas, including nurse practitioners, physician assistants, and certified nurse midwives in determining the clinician-to-population ratios used in establishing "unmet need" for placement purposes.

    Recommendation: To better target limited resources, the Secretary of Health and Human Services should modify placement criteria to include a single measure of need that: (1) counts nonphysician providers and NHSC providers currently in service; and (2) specifies the minimum number of providers needed to relieve shortages.

    Agency Affected: Department of Health and Human Services

  2. Status: Closed - Implemented

    Comments: HHS has initiated some measures to help NHSC to assist as many shortage areas (HPSA) as possible, including a site-specific limit on the number of NHSC vacancies, and counting NHSC clinicians serving in the area in determining the clinician-to-population ratios used in establishing "unmet need" for placement purposes. While these initiatives could lead to the distribution of NHSC providers to more HPSAs, because the NHSC does not limit placement to the shortage area de-designation level, these measures do not prevent placement of NHSC providers in shortage areas in excess of identified need while other eligible applicants are underserved.

    Recommendation: To better target limited resources, the Secretary of Health and Human Services should position NHSC to assist as many shortage areas as possible by discontinuing the practice of placing providers in shortage areas in excess of identified need while other eligible applicants are underserved.

    Agency Affected: Department of Health and Human Services

  3. Status: Closed - Implemented

    Comments: HHS had its technical assistance contractor submit a report on shortage areas with no NHSC providers or requests for NHSC assistance, and has acknowledged that there is room for improvement, particularly in areas of coordination between the NHSC and primary care offices in providing technical assistance, and in offering recruitment assistance to needy communities. NHSC officials said that they have undertaken a series of conferences in fiscal year 1997, targeted specifically at improving the site development process.

    Recommendation: To better target limited resources, the Secretary of Health and Human Services should assess the reasons why a significant number of eligible areas are not applying for NHSC resources and expand technical assistance and other efforts to address potential barriers to assessing this program.

    Agency Affected: Department of Health and Human Services

  4. Status: Closed - Implemented

    Comments: Current allocations for the programs (scholarships and loan repayments) are split 40/60, which maximizes the loan repayment program to the fullest extent of the law. HHS views the federal and state loan repayment programs as complementary programs, and commented that it weighs the differences in the programs in its ongoing assessment of the costs and benefits of the programs to NHSC long-term recruitment and retention efforts.

    Recommendation: To better target limited resources, the Secretary of Health and Human Services should apportion future NHSC funding to use the loan repayment program to the maximum extent allowed by law. Similarly, the Secretary should assess whether the benefits of the state loan repayment program, which is less costly, are such that they would warrant greater use of the program.

    Agency Affected: Department of Health and Human Services

 

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