Department  of  Health  and  Human  Services 
OFFICE  OF 
INSPECTOR  GENERAL 
NATIONAL  HEALTH  SERVICE  CORPS: 
A  SURVEY  OF  PROVIDERS,  FACILITIES, 
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AND  STAFF 
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OEI-O9-91-O131O  OFFICE  OF INSPECTOR  GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 
amended, is to protect the integrity of the Department of Health and Human Services (HHS) 
programs as well as the health and welfare of beneficiaries served by those programs.  This 
statutory mission is carried out through a nationwide network of audits, investigations, and 
inspectionsconductedby three OIGoperatingcomponents: the OffIceof AuditServices,the 
OffIceof Investigations,andthe OffIceof EvaluationandInspections. The OIGalso informsthe 
Secretaryof HHSof programandmanagementproblemsandrecommendscoursesto correctthem. 
OFFICE  OF AUDIT  SERVICES 
The OIGSOftlceof AuditServices(OAS)providesall auditingservicesfor HHS, eitherby 
conducting audits with its own audit resources or by overseeing audit work done by others.  Audits 
examine the performance of HHS programs and/or its grantees and contractors in carrying out 
their respectiveresponsibilitiesand are intendedto provide independentassessmentsof HHS 
programs and operations in order to reduce waste, abuse, and mismanagementand to promote 
economy and efficiency throughout the Department. 
OFFICE  OF INVESTIGATIONS 
The OIGSOftlce of Investigations(01) conductscriminal, civil, and administrativeinvestigations 
of allegations of wrongdoing in HHS programs or to HHS beneficiaries and of unjust enrichment 
by providers.  The investigativeefforts of 01 lead to criminal convictions, administrative 
sanctions, or civil money penalties.  The 01 also oversees State Medicaid fraud control units which 
investigate and prosecute fraud and patient abuse in the Medicaid program. 
OFFICE  OF EVALUATION  AND INSPECTIONS 
The OIGSOffice of Evaluation and Inspections (OEI) conducts short-term management and 
program evaluations(calledinspections)that focuson issuesof concernto the Department,the 
Congress, and the public.  The findings and recommendationscontained in these inspection reports 
generate rapid, accurate, and up-to-date information on the efilciency, vulnerability, and 
effectivenessof departmentalprograms.  This reportwasprepared inthe SanFranciscoregional 
office under the direction of Regional Inspector General Kaye D. Kidwell and Deputy Regional 
Inspector General Paul A. Gottlober.  Project staff included: 
SAN FRANCISCO  HEADQUARTERS 
Elizabeth Celniker  W. Mark Krushat

Robert Gibbons  Barbara Tedesco

Deborah Harvey  David Wright

Ellen Kotler  Ta Zitans

Donald Loeb

Brian Pattison

Tom Purvis

Brad Rollin
 Department  of  Health  and  Human  Services 
OFFICE  OF 
INSPECTOR  GENERAL 
NATIONAL  HEALTH  SERVICE  CORPS: 
A  SURVEY  OF  PROVIDERS,  FACILITIES, 
I 
AND  STAFF 
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OEI-O9-91-O131O  EXECUTIVE  SUMMARY 
PURPOSE 
This inspection  assesses the impact of the National  Health  Service Corps policies, 
practices,  and requirements  on health care providers  and the facilities  where  they serve. 
BACKGROUND 
After years of sharp budget  reductions,  Congress and the Department  of Health  and 
Human  Services  have initiated  a revitalization  of the National  Health  Service  Corps 
program  (hereafter  referred  to as the Corps).  As part of this revitalization,  the Office 
of the Secretary  asked the Office of Inspector  General  (OIG) to provide  information  on 
Public Health  Service  (PHS) and Corps policies  and how they affect health care providers, 
such as physicians,  nurse practitioners,  and dentists,  and the facilities  where they serve. 
In addition,  the Assistant  Secretary  for Legislation,  the Assistant  Secretary  for Planning 
and Evaluation,  and the Assistant Secretary  for Management  and Budget requested  that the 
OIG provide  information  on the Corps ability to expand in the future:  -
The Corps is a Federal  program  designed  to reduce or eliminate  health professional 
shortages  in local communities.  Congress  created  the Corps in 1970 to improve  the 
delivery  of health  services  to communities  where health personnel  and services  are 
inadequate  to meet the health needs of the residents  of such communities  and areas.   The 
Corps grew  rapidly  until budget  constraints  and predictions  of physician  surpluses  led to 
reductions  during  the  1980s.  As a result,  the number  of newly awarded  scholarships 
declined  from a high of 2,380  single-year  awards in  1979 to 40 multi-year  awards  in 
1988. 
Despite  the continued  prediction  of a national physician  oversupply,  there is a shortage  of 
primary  care providers.  Approximately  22 million Americans  lack adequate  access to 
medical care,  and millions more lack adequate  access to dental and/or  mental health care. 
Physician  availability  in counties with small populations  is less than a third of the national 
average.  Inner cities face similar problems.  Drug abuse and the AIDS epidemic  have 
made practicing  medicine  more dangerous  and have driven providers  into safer 
neighborhoods. 
Congress  took two major actions to address these ongoing problems.  In 1987, it 
established  the loan repayment  program  to attract providers  who could  serve immediately 
in medically  needy areas.  Then in 1990, it enacted the Revitalization  Amendments  which 
increased  the Corps appropriation  from $51 million to $91 million.  Since then, 
expansion  has continued.  According  to PHS,  the Corps will offer approximately 
400 scholarships  and 600 loan repayments  in 1994, as contrasted  to 49 and  112 in 1989.  We conducted  telephone  and in-person  interviews  with a national  random  sample of 
302  providers  from  13 strata.  We asked them about recruitment,  matching  to a facility, 
retention,  defaulting,  communication  with PHS,  and suggestions  for improvement.  We 
also conducted  telephone  and in-person  interviews  with a random  sample of 30 directors 
from facilities  where a Corps provider  has served during  the last 7 years.  In addition  to 
the provider  and facility  director  interviews,  we conducted  interviews  with PHS central 
and regional  office staff.  We asked the staff to address  specific comments,  concerns,  and 
problems  that were reported  by providers  and facility directors,  as well as recent  efforts to 
revitalize  the Corps,  the Corps expansion  strategy,  and its ability to expand in the future. 
FINDINGS 
Health facilities  depend  on the Cotps for  quality providem 
Ninety percent  of facility directors  believe  that their facilities  could not adequately  serve 
patients  without Corps providers. 
Acconiing  to providers,  directors,  and PHS staff,  more frequent  and better 
communiction  is essential for  Cops  morale and expansion 
The PHS officials  do not routinely  initiate contact,  and providers  and facilities  do not 
know whom to call with questions or concerns.  Both PHS and related  agencies  do not 
provide  enough outreach  and technical  assistance  to existing and potential  facilities. 
Providens and directons are dissatisfied  with the matching process 
Providers  believe  PI-IS gave them inadequate  information  and assistance  before  and during 
the matching  process.  In addition,  the vacancy lists do not contain  complete  and current 
information. 
Although  many factors  affect  retention, facilities  and PHS plizy key roles 
More  than one-third  of scholars and loan repayers  stay at Corps facilities  more than a year 
after their obligation  has ended.  Crucial  factors affecting  retention  include  facilities 
treatment  of providers,  family concerns,  financial incentives,  and professional  support. 
PHS policies  are not jlexible  enough to address pmvidem  needs and preferences 
More  than 50 percent  of providers  cited problems  with inflexible  Corps policies  and/or 
suggested  that PHS policies  should be more flexible. 
Competition,  availability,  and site limitations  may hinder the expansion  of the loan 
repayment prognzm 
Three  factors  limit the number  of people who enter the loan repayment  program: 
ii
 (1) the small number  of primary  care providers  overall,  (2) competition  from group 
practices  and managed  care organizations,  and (3) the limited  number  of attractive, 
available  sites approved  for loan repayers. 
Nu~e  pmctitiwen,  physician  assistants,  and certified  nume midwives frequently  face 
pmctice  barriem 
Almost three-fourths  of nurse practitioners,  physician  assistants,  and certified  nurse 
midwives  reported  facing barriers  to providing  medical  care. 
The check disbumement  process  could be improved 
More  than one-third  of loan repayers  and a few scholars described  problems  related  to 
their financial  disbursements  from PHS. 
RECOMMENDATIONS 
PHS shouki improve  its communication  with and support for providem  and facilities 
Good communication,  adequate  support,  and outreach  are essential  to maintain  and 
increase  provider  morale and satisfaction. 
PHS should  consider more jlexible  matching  and pmctice  policies 
Increased  flexibility  would improve  retention  and provide  better  solutions to the shortage 
of health care providers. 
PHS should develop  more accumte,  complete,  and up-to-date  vacancy  lists 
Insufficient,  inaccurate,  and outdated  information  hamper  the matching process. 
PHS should use direct deposit to pay providers 
Loan repayers  and scholars  have difficulties  receiving  their checks on time and at the 
correct  address. 
AGENCY  COMMENTS  AND  OIG  RESPONSE 
In written  comments  on the draft report,  PHS concurred  fully or in part with all of the 
reports  recommendations  and described  the actions they already  have taken or plan to 
take.  The full text of PHS comments  appears in Appendix  B.  In response  to PHS 
comments,  we have made some technical  corrections.  We recognize  and support the 
numerous  improvements  that PHS has made and plans to make to improve  communication 
and support,  flexibility,  vacancy list accuracy,  and monetary  disbursement. 
... 
111  TABLE  OF  CONTENTS

EXECUTIVE  SUMMARY

INTRODUCTION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

FINDINGS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6


Dependence ontheCorps.  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...6

  N~formore  frequent and better communication  . . . . . . . . . . . . . . . . . . . . 6


Dissatisfaction  withthematching  process  . . . . . . . . . . . . . . . . . . . . . . . ...8

 
pHSand  facilitiesroles  in retention  . . . . . ..  O..  O.O . . . . . . . .00.0...9

11

.Inflexiblepolicies..o  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
11

.~anrepaymentprogram  expansio  n . . . . . . . . . . . . . . . . . . . . . . . . . . . 
 
12

practice  barriers  ...,  . . . . . . . . . . . . . . . . . ...  D O . . . . . . . . . . . . .0 
13

ch~kdisbursement...  . . . . . . . . . ..  OO.O..  . . . . . . . . . . . . . . . . . . 
RECOMMENDATIONS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  14

APPENDICES  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

A:  Sample selection  methodology,  estimates,  and confidence  intervals  . . . . . . . . .  A-1

B:  PHS comments  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..B-l
 INTRODUCTION 
PURPOSE 
This inspection  assesses the impact of the National  Health Service  Corps policies, 
practices,  and requirements  on health care providers  and the facilities  where  they serve. 
BACKGROUND 
After years of sharp budget  reductions,  Congress  and the Department  of Health  and 
Human  Services  have initiated  a revitalization  of the National  Health Service  Corps 
program  (hereafter  referred  to as the Corps).  As part of this revitalization,  the Office 
of the Secretary  asked the Office of Inspector  General  (OIG) to provide  information  on 
Public Health  Service  (PHS) and Corps policies and how they affect health care providers, 
such as physicians,  nurse practitioners,  and dentists,  and the facilities  where  they serve. 
In addition,  the Assistant Secretary  for Legislation,  the Assistant  Secretary  for Planning 
and Evaluation,  and the Assistant Secretary  for Management  and Budget requested  that the 
OIG provide  information  on the Corps ability to expand in the future. 
History 
The National  Health  Service Corps is a Federal  program  designed  to reduce  or eliminate 
health professional  shortages  in local communities.  Congress  created  the Corps in 1970 
by enacting  the Emergency  Health  Personnel  Act.  This legislation  enabled  PHS to send 
volunteers  and Federal  health care providers  to improve  the delivery  of health  services  to 
communities  where  health personnel  and services  are inadequate  to meet the health needs 
of the residents  of such communities  and areas.   In 1972, Congress  established  a 
scholarship  program  that allowed PHS to offer scholarships  to medical  students in 
exchange  for service in the Corps. 
The Corps grew rapidly  until budget constraints  and predictions  of physician  surpluses led 
to reductions  during  the 1980s.  As a result,  the number  of newly awarded  scholarships 
declined  from a high of 2,380  single-year  awards  in 1979 to 40 multi-year  awards  in 
1988. 
Millions  of Americans  Lack Adequate  Access to Health  Care 
Despite  the continued  prediction  of a national physician  oversupply,  PHS estimates  that 
approximately  22 million Americans  lack adequate  access to medical  care,  and millions 
more lack adequate  access to dental and/or  mental health care.  Physician  availability  in 
counties  with small populations  is less than a third of the national  average.  Inner cities 
face similar problems  with physician  access.  Drug abuse and the AIDS epidemic  have 
made practicing  medicine  more dangerous  and have driven providers  into safer 
neighborhoods. 
1  A major factor  in this shortage is the lack of primary  care providers.l  Primary  care 
providers,  in contrast  to non-primary  care  specialists,  provide  a broad range  of services  to 
meet patients  health needs.  In an area with few health care professionals,  a primary  care 
provider  may serve all of the publics health care needs.  Although the total number  of 
physicians  has grown over the past several decades,  the percentage  who are primary  care 
physicians  has declined. 
Responding  to the Primary  Care Shortage 
During  the late  1980s and early  1990s, Congress  took several  steps to respond  to the 
shortage  of primary  care providers.  Specifically,  Congress: 
F established  a loan repayment  program  in  1987 to complement  the Corps 
scholarship  program  by attracting  health care providers  who could  serve 
immediately  in medically  needy areas and 
  enacted  the National  Health  Service Corps Revitalization  Amendments  of 
1990 which almost doubled the Corps appropriation  from $51 million  to 
$91 million. 
Since then,  expansion  has continued.  According  to PHS officials,  the Corps will offer 
approximately  400 scholarships  and 600 loan repayments  in 1994, as contrasted  to 
49 and  112 in 1989. 
Program  Oversight 
Depending  on the region and State, a number of agencies  are responsible  for overseeing, 
assisting,  and supporting  Corps providers  and facilities.  Within PHS,  the Division  of 
National  Health  Service  Corps and regional  offices oversee  most aspects of the program. 
The Division  of Scholarships  and Loan Repayments,  Division  of Shortage  Designation, 
and Division  of Fiscal  Services also oversee  and administer  the program  at the central 
office level.  At the regional,  State, and local levels,  PHS has cooperative  agreements 
with all 50 States and works with numerous  primary  care associations  to help administer 
the program.  While their duties vary by region and State,  these agencies  generally  help 
facilities  apply for Corps providers,  help recruit  and retain providers,  and provide 
continuing  assistance.  They also help providers  obtain further  training  and education  and 
establish  linkages  with other health professionals. 
HOW  THE  NATIONAL  HEALTH  SERVICE  CORPS  WORKS 
The PHS helps match Corps providers  to needy facilities  in both rural  and urban areas. 
All providers  must serve  1 year for each year they receive  Corps  support,  with a 
1 The  Corps  list of primary  care  fields  includes  family  practice,  osteopathic  general  practice,  pediatrics, 
internal  medicine,  general  psychiatry,  obstetrics/gynecology,  dental  general  practice,  nurse  practitioner 
practice,  physician  assistant  practice,  and  certified  nurse  midwifery. 
2  minimum  2-year  commitment.  Scholarship  and loan repayment  applicants  experience 
different  application  and site matching processes.  Facilities  undergo  a separate  application 
process  and are responsible  for encouraging  providers  to remain  in the community  after 
they complete  their obligations. 
How do providers  enter the Coqos? 
Students planning  to enter primary  care fields may compete  to receive  scholarships  to pay 
for their training.  Students apply to PI+S Division  of Scholarships  and Loan Repayments 
which scores each application.  The PHS central  and regional  offices interview  applicants 
who receive  high scores to ensure  that they are aware of the programs  requirements  and 
the unique demands  of serving a medically  needy population.  The PHS scores all 
interviews  and awards  scholarships  based on the combined  score of the written  application 
and interview. 
Loan repayment  applicants  enter the program  when they finish their training  and are ready 
to start working.  For the most part,  providers  either  (1) obtain a list of eligible  facilities 
and complete  the paperwork  upon reaching  an agreement  to work for a facility or 
(2) apply for and receive  loan repayment  through eligible  facilities  that use the Corps 
loan repayment  program  as part of a benefit package.  In general,  applicants  automatically 
receive  loan repayment  as long as they are qualified,  licensed  to practice  in that State,  and 
match to an eligible  facility.  In addition  to receiving  salaries  from facilities,  loan repayers 
receive  lump-sum  or quarterly  checks from PHS to repay  their loans.  Loan repayers  are 
eligible  to receive  up to $35,000  per year. 
How do facilities  apply for  providers,  and how does PHS rank their need for  assistance? 
Individual  facilities  submit applications  for providers  to PHS.  To be eligible  for 
assistance,  the facility  must be located in a federally-designated  Health Professional 
Shortage  Area  (HPSA).  The criteria  that PHS uses to designate  HPSAS include 
(1) the ratio of providers  to area residents,  (2) low birthweight,  infant mortality,  and 
poverty  rates,  and (3) access to primary  care services,  taking into account  the distance  to 
such services.  Sites must be in the neediest HPSAS to be eligible  for Corps assistance. 
The PHS scores applications  from facilities  located within these high need areas and 
places  them on one of three vacancy lists: 
b  Health Professional Shortage Area Placement Oppotiuni~ List (HPOL): 
Scholarship  recipients  must fulfill their obligation  at these facilities  which are 
located  in communities  with the greatest  need for providers.  The PHS develops 
separate  HPOLS for each medical  specialty.  The number  of facilities  on each 
HPOL  is set by law--three  facilities per available  scholarship  recipient--in  order  to 
ensure  that the neediest  communities  have a good chance  to obtain a provider.  For 
example,  if 16 family practitioners  were available  for placement,  their HPOL 
would consist of the 48 facilities  that have the greatest  need for family 
practitioners. 
3  Although  the three-to-one  ratio was designed to ensure that providers  were offered 
an adequate  selection  of sites, the small number of available  scholarships  limited 
their options.  In response,  PHS recently  began using a questionnaire  to assess 
providers  interests,  spouses needs,  and geographic  preferences  to add facilities  to 
the HPOL if a providers  placement  there would result  in a long-term  solution to a 
communitys  primary  care shortage. 
F	 Loan Repayment VacancyList:  These facilities  generally  have less critical  need for 
providers  than facilities  on the HPOL.  This list offers loan repayers  more options 
in matching  to a facility than the HPOL. 
Volunteer VacancyList:  Many sites meet the minimum  criteria  for Corps 
P	
assistance  but are not as needy as the sites on the HPOL  or loan repayment  list. 
The PHS makes a list of these sites available  to providers  who do not receive 
scholarships  or loan repayment  but wish to serve in a needy community. 
How do providers  get assigned to facilities  ? 
When  scholarship  recipients  complete  medical  school and their residency,  they must begin 
serving their obligation.  The first step is matching  to--or reaching  an agreement  to 
work for--an eligible  site.  The PHS provides  scholarship  recipients  with the appropriate 
HPOL  for their  medical  specialty.  Providers  can attempt  to get hired by any facility on 
that list.  The PHS may assign providers  to facilities  if they have not matched  themselves 
after 9 months. 
Loan repayers  have more options than scholarship  recipients  during  the matching process. 
The PHS provides  copies of the HPOL and loan repayment  vacancy  lists to providers 
interested  in receiving  loan repayment.  Upon matching  to an eligible  facility,  the provider 
or facility  submits the paperwork  for loan repayment. 
What are the requirements for providers  who are serving their obligations? 
Providers  must meet certain  requirements  while serving at facilities.  The PHS requires 
that providers  are licensed  in their assigned States and that they engage in full-time 
medical practice,  defined  as 40 hours per week.  At least 32 hours per week (21 hours  for 
obstetricians)  must be spent providing  clinical  services at the facility. 
In addition,  providers  must meet all normal  State requirements  regarding  their practice. 
This is particularly  an issue for nurse practitioners,  physician  assistants,  and certified 
nurse  midwives,  whose ability to practice  independently  and write prescriptions  depends 
on State law. 
W%&happens  to providers  who experience problems  while serving their obliga.tzons? 
A difficult  placement,  poor relationship  with the facility  management,  or any number  of 
other professional  or personal  problems  may pose barriers  to providers  completing  their 
4  obligations.  The PHS conducts orientation  sessions and makes efforts  to familiarize 
providers  with the staff they should contact  if they have problems.  The PHS is supposed 
to provide  support and mediate disputes between providers  and facilities.  If the problems 
persist,  however,  providers  may request  transfers  or subsequently  default on their 
obligations.  Generally,  providers  must serve at least  1 year at a facility before  they are 
eligible  for a transfer.  Providers  who fail to meet any of the Corps requirements  are 
placed  into default  status.  The PHS imposes severe penalties  to discourage  providers  from 
defaulting. 
W%alhappens  @er  pmvidens  complete their obligtions? 
The PHS encourages  facilities  to develop effective plans to retain providers  who are 
completing  their obligation  in order  to eliminate  health provider  shortages permanently. 
Although the facility is primarily  responsible  for designing  the retention  package,  PHS 
may offer assistance  and guidance  to the provider  and/or  facility. 
METHODOLOGY 
We interviewed  a national  random  sample of 302 Corps providers  drawn from a universe

of 1,856.  We selected providers  from  13 strata,  The strata were based on type of

assistance,  year,  and timing in the program.  We included  special  strata for

(1) nurse practitioners,  physician  assistants,  certified  nurse  midwives and

(2) obstetrician/gynecologists.  During  telephone  and in-person  interviews  during  the Fall

of 1992, we asked providers  about recruitment,  matching  to a facility,  retention,

defaulting,  communication  with PHS, and suggestions  for improvement.  For a more

detailed  description  of the sample selection  methodology,  please refer  to the appendix.

We also conducted  telephone  and in-person  interviews  with a simple,  random  sample of

30 directors  from the 2,284  facilities  where a Corps provider  has served during  the last

7 years.  We asked the directors  about (1) the matching process,  (2) recruitment  and

retention,  and (3) the Corps policies,  staff, and providers.

In addition  to the provider  and facility director  interviews,  we conducted  interviews  with

PHS central  and regional  office staff.  We asked the staff to address  specific comments,

concerns,  and problems  that were reported  by the providers  and facility directors,  as well

as recent  efforts  to revitalize  the Corps,  the Corps expansion  strategy,  and its ability to

expand in the future.

5  FINDINGS

HEALTH  FACILITIES  DEPEND  ON  THE  CORPS  FOR  QUALITY  PROVIDERS 
Ninety percent  of facility directors,2 hereafter  called  directors,  believe  that their 
facilities  could not adequately  serve patients  without Corps providers.  Both directors  and 
providers  believe  that the Corps presence  has led to new or expanded  services,  greater 
access to care,  and improved  financial  stability. 
Directors  praise  the overall  quality of the providers.  They are impressed  with providers 
technical  expertise  and personal  commitment.  Many of them believe  that without the 
Corps they would not be able to attract the same quality of providers.  Eighty  percent  of 
directors  say they need at least one more provider  to offer adequate  health care in their 
communities.  Because of their locations and inability  to offer competitive  salaries, 
two-thirds  of directors  believe  they will always need the Corps to recruit  providers  for 
their communities. 
However,  approximately  half of the loan repayers  said they would have worked at the 
facility even if they had not received  loan repayment.  Most of these providers  said they 
do not plan to stay at the facility just because  the Corps repaid  their loans. 
ACCORDING  TO  PROVIDERS,  DIRECTORS,  AND PHS  STAFF,  MORE 
FREQUENT  AND  BETTER  COMMUNICATION  IS  ESSENTIAL  FOR  CORPS 
MORALE  AND  EXPANSION 
Early  and continuing  contact  educates providers  and facilities  about procedures,  agency 
responsibilities,  and available  assistance.  Furthermore,  communication  helps avoid and 
mitigate problems  among providers,  facilities,  and Federal  officers.  Poor communication 
can lead providers  to default,  request  transfers,  leave after their obligation,  and/or 
discourage  others  from joining  the Corps. 
Providers  and directors  offered  comments  about the lack of regular  contact,  a specific 
contact person,  outreach,  technical  assistance,  and responsiveness  of PHS.  More  than 
35 percent  of providers  who call PHS with questions or concerns  claim  that PHS staff are 
not responsive  to their needs.  Providers  described  receiving  inconsistent  interpretations  of 
policies  and inadequate  follow-up when they raised questions about problems  they were 
having in their assigned  facilities. 
2 We included  the confidence  intervals  for all percentages  in this  report  in the appendix. 
6  PHS officials  do not routinely  intie  contact,  and providem  and facilities  do not know 
whom to call with questzonsor concerns 
According  to providers,  PHS regional  and central  office staff did not routinely  contact

them.  More  than one-quarter  of all providers  recalled  no contact  with PHS.

Fifty-six  percent  of scholars and 42 percent  of loan repayers  placed in  1991 believe  PHS

does not contact them often enough.

Providers  and directors  often do not know whom to contact  when they have questions  or

concerns.  Depending  on the question,  they may have to contact  the regional  office,  the

primary  care association,  the State agency,  or one of several divisions  in the central

office.  In addition,  the responsibilities  of many offices and agencies  vary by region and

type of facility.  Providers  would prefer  to have a single person  to contact  when they have

questions.

PHS and reWed  agencies  do not provide  enough outreach  and technical  assistance  to 
exiting and potential facilities 
Although  PHS officials  acknowledge  the importance  of site development  and recognize  the 
need to work with facilities  to ensure  that providers  receive  adequate  professional  and 
financial  support,  site development  has not been a PHS priority  in recent  y~s.  As a 
result,  many directors  do not understand  the roles and responsibilities  of PHS and related 
agencies.  Furthermore,  many new directors  did not know about the Corps existence  or 
were unaware  that the Corps is expanding.  The lack of knowledge  is especially  evident in 
facilities  that do not receive  Federal  funds,  facilities  with high administrative  turnover, 
and/or  small rural  facilities. 
Directors  commented  on the need for outreach  and clearly  defined  roles among  PHS and 
related  agencies.  Directors  rarely  receive  technical  assistance  from PHS,  primary  care 
associations,  or State agencies.  Twenty-five  percent  of directors  did not know that PHS 
provides  technical  assistance,  and 30 percent  of directors  recalled  being offered  technical 
assistance  by regional  offices.  Some directors  were not aware  that primary  care 
associations  and State agencies  help administer  the Corps.  Thirty  percent  of directors  had 
no interaction  with primary  care associations  and State agencies. 
Directors  want more on-going  technical  assistance  in areas ranging  from the application  to 
provider  retention.  For example,  approximately  50 percent  of directors  believe  that the 
application  process  is burdensome.  Lacking  technical  assistance,  facilities  have trouble 
collecting  the data necessary  for the Corps application.  Insufficient  or problematic  data 
can lead to denied applications  for assistance. 
7  PHS officials  recognize  the need for  revised management  pructices  to imprwe 
communication  and accommodate  expansion 
Regional  office staff predict  that expansion  will force them to reduce  their recruitment, 
site development,  and oversight  activities.  In response  to these workload  concerns,  PHS 
central  office plans to rely on agreements  with State agencies  and primary  care 
associations  to perform  some of these vital functions.  Both regional  and central  office 
staff caution  that some States will not be able to assume  more responsibilities  and that 
specific guidance  needs to be developed  to define appropriate  roles and responsibilities. 
Expansion  also will require  greater  communication  and coordination  among PHS 
components.  Staff in 9 out of 10 regions believe  that the Division  of Scholarships  and 
Loan Repayments  and the Division  of National  Health Service  Corps need to communicate 
better,  coordinate  their workplans,  and develop and implement  consistent  policies  and 
procedures.  To address these concerns,  program  officials are examining  ways to use their 
resources  more efficiently  by improving  their data and information  systems and 
simplifying  reporting  requirements. 
PROVIDERS  AND  DIRECTORS  ARE  DISSATISFIED  WITH  THE  MATCHING 
PROCESS 
A majority  of providers  and one-third  of directors  were dissatisfied  with the matching 
process.  More than 60 percent  of providers  who participated  in the matching  process 
were dissatisfied  with the number  and variety  of facilities  available.  Seventy percent  of 
scholars placed in  1991 were dissatisfied  with the matching process,  and 60 percent  of all 
providers  who experienced  a problem  during their obligation  attributed  it to the matching 
process.  Providers  and directors  are dissatisfied  with the matching process  because 
(1) they receive  inadequate  information  from PHS and (2) the HPOL  and loan repayment 
vacancy  list lack complete  and current  information. 
Providers  believe  PHS gave them inadequate  information  and assistance  before and 
during the ma/thing  process 
Almost 30 percent  of providers  believe  that PHS does not adequately  describe  the 
matching  process  and the facilities  available  for placement.  More  than one-quarter  of 
providers  who matched  to a facility commented  that they had expected  the HPOL  and the 
loan repayment  vacancy  list to contain  more facilities  nationally  or in specific areas. 
Some providers  further  indicated  that PHS staff gave them incorrect  information  about the 
facilities  that would be available. 
Since  1989, PHS has made an effort  to educate and prepare  scholars better by 
interviewing  top applicants.  Our data reflect  this effort.  More  1989 and 
1991 scholarship  recipients  mentioned  that PHS is providing  information  about available 
locations  and facilities  and explaining  how PHS develops the HPOL than prior  scholars. 
8  Many providers  do not recall  receiving  adequate  assistance  from PHS during  matching. 
More  than half of the providers  placed in 1991 recalled  receiving  only the list and no 
further  assistance.  Some providers  said this is due partly  to PHS incomplete  knowledge 
of the facilities  and surrounding  communities. 
The vacancy lists do not contain  complete  and current infotma.hon 
Directors  and providers  suggest that PHS should provide  more timely and complete 
information  to facilitate  matching.  Twenty percent  of directors  believe  that the 
information  on the HPOL and loan repayment  vacancy  list is inadequate  and that providers 
do not get a good picture  of facilities.  Providers  further  commented  that the lists 
contained  outdated  and incomplete  information  and listed facilities  without vacancies. 
Directors  and providers  suggested  that an on-line,  or otherwise  continually  updated, 
system of eligible  facilities  be available.  Similarly,  several PHS staff suggested  on-line 
community  profiles  and tracking  systems,  which PHS is now developing  on a pilot basis. 
Directors  also suggest that PHS provide  additional  information  about the providers  who 
are looking  for vacancies,  so they can better  market their facilities.  They  suggest that the 
list of eligible  providers  include information  such as language  skills or providers  outside 
interests. 
ALTHOUGH  MANY  FACTORS  AFFECT  RETENTION,  FACILITIES  AND  PHS 
PLAY  KEY  ROLES 
More  than one-third  of scholars and loan repayers  stay at their assigned  facilities  more 
than a year after they complete  their obligation.  Although the data do not show any 
significant  difference  in actual retention  between loan repayers  and scholars,  more loan 
repayers  say they plan to stay at the facility after their obligation.  That  may be due to the 
fact that many loan repayers  worked at the facility before joining  the Corps. 
Some providers  credited  personal  satisfaction  with their work as the reason  for staying. 
On the other hand,  some mentioned  conflicts  with the facilitys administration  as the 
reason  for leaving.  Physician  assistants and certified  nurse midwives  appear  to have 
higher retention  rates than other providers.  Furthermore,  rural providers  are more likely 
to remain  after  their obligation  than urban providers. 
Providers  and directors  offered  a variety  of ways that PHS and facilities  could improve 
morale  and retention.  Increased  flexibility  of PHS policies  is a common  suggestion.  We 
discuss flexibility  in more detail in the finding on page  11.  Other suggestions  to improve 
provider  morale  and retention  include  (1) fair treatment  of providers  by facilities, 
(2) financial  incentives,  and (3) adequate  support of providers  in their  settings. 
9  Facilities treatment  of providem  is crucial to retention 
Almost two-thirds  of directors  believe  their role in retention  is to offer providers  exciting 
and attractive  work environments.  Facilities  with high retention  rates cite fair treatment 
of providers  as the key to their success.  These directors  treat the providers  as equals, 
involve  them in the decision-making  process,  and make them feel welcome  in the 
community.  They believe  this approach  helps providers  grow  roots  that may prevent 
them from leaving. 
Although providers  also believe  that fair treatment  by facilities  is essential  for retention, 
many described  negative  experiences.  Some providers  believe  facility administrators  lack 
of understanding  results  in overly  ambitious  patient  loads,  poor working  conditions  for all 
providers,  and high turnover  among  medical  staff.  Some providers  say they would be 
more likely to stay if the facility gave them greater  responsibility  and autonomy,  managed 
workloads  better,  replaced  incompetent  administrators,  and/or  provided  additional 
opportunities  for professional  training. 
Financiul incentives  affect  retention 
Although  factors  such as family concerns  and treatment  by the facility are  more important, 
almost  half of providers  and 80 percent  of directors  believe  adequate  compensation  is 
crucial.  Providers  suggest that higher  salaries and better benefits  would make them more 
likely to stay.  Some providers  also are willing to sign extended  commitments  in exchange 
for repayment  of additional  educational  loans.  Others seek higher  salaries because  their 
spouses cannot  earn enough income  in underserved  areas.  Some facilities  with high 
retention  rates use incentive  programs,  in which salary bonuses are based on productivity. 
Directors  also suggest that tax breaks,  bonuses that are not tied to productivity,  and 
Federal  malpractice  coverage  for all facilities  would increase  retention. 
Luck of professional  suppoti  can huti  retention and mode 
Providers  stated that their inability  to interact  with other health professionals  and the lack 
of clinical  and administrative  support frustrates  their attempts  to provide  quality care and 
contributes  to bum-out.  Twenty-three  percent  of directors  agree  with providers  that 
professional  support is essential  for clinical  success and retention.  Both directors  and 
providers  suggested  that PHS place providers  in settings that can ensure an adequate  level 
of support. 
Provider  burn-out  is common in small practice  settings.  Several  sampled providers 
defaulted  on their obligations,  while others  stayed simply because  the communitys  need 
for their  services  was so great. 
Providers  in the private  practice  option have a special need for support and assistance, 
because  they are often in small practice  settings and have the added responsibility  of 
running  a business.  Only a small number of providers  exercise  the private  practice 
10  option,  because  most needy communities  cannot support a financially  viable private 
practice. 
PHS  POLICIES  ARE  NOT  FLEXIBLE  ENOUGH  TO  ADDRESS  PROVIDERS 
NEEDS  AND  PREFERENCES 
More than 50 percent  of providers  cited problems  with inflexible  policies  or suggested that 
PHS policies  should be more flexible.  Providers  believe  that greater  consideration  of 
individual  situations  in matching,  transfer,  and clinical practice  policies  would not hinder 
the Corps  ability to serve the neediest areas. 
Many providers  believe  that inflexible  matching policies  hinder their productivity, 
long-term  retention,  and lifestyle.  Providers  wonder why they are not allowed  to choose 
an area where  they are more likely to stay permanently.  Some providers  leave their 
families behind because  of poor employment  opportunities  for their spouses or educational 
opportunities  for their children.  Many providers  reported  that their placement  choices 
consisted  solely of communities  where they face discrimination  or bigotry  based on race, 
gender,  sexual orientation,  or religion. 
In an effort  to address providers  needs and wishes,  PHS began using the Professional 
Training  Information  Questionnaire  in 1992.  Most providers  we interviewed  had no 
experience  with this questionnaire,  because  they were already  assigned to a Corps  facility 
or still in training. 
Some providers  want more flexible transfer  policies  so they can move if they encounter 
problems  at a Corps  facility.  By transferring,  they could continue  serving  instead of 
defaulting  or leaving at the end of their obligation.  Approximately  one-quarter  of 
providers  who attempted  to transfer  experienced  difficulties.  They stated that PHS offered 
little or no assistance  and discouraged  their attempts  to transfer. 
Several PHS officials  suggested that greater  flexibility  would bolster  both recruitment  and 
retention.  They  specifically  suggested  that PHS offer  (1) scholars  more choices  of 
facilities  during  the matching process  and (2) part-time  options with extended  payback 
periods  for all providers.  Providers  echoed these suggestions  and said they would be 
willing to extend their obligations  in exchange  for these options. 
COMPETITION,  AVAILABILITY,  AND  SITE  LIMITATIONS  MAY  HINDER  THE 
EXPANSION  OF  THE  LOAN  REPAYMENT  PROGRAM 
The PHS may encounter  difficulties  attracting  enough providers  into an expanded  loan 
repayment  program.  Three  factors limit the number of people  who enter  the loan 
repayment  program:  (1) the small number of primary  care providers  overall, 
(2) competition  from group practices  and managed care organizations,  and (3) the limited 
number  of attractive,  available  sites approved  for loan repayers. 
The loan repayment  program  recruits  from the limited pool of approximately 
11  11,500 primary  care providers  and general  dentists who complete  their training  and enter 
practice  each year. 3  Some of these primary  care providers  are not available  for loan 
repayment  service,  because  they already  have service obligations  to Federal,  State,  or 
local governments  or private  organizations.  Many additional  internal  medicine  and 
pediatrics  residents  are not available  for loan repayment  recruitment,  because  they choose 
to specialize  further  in non-primary  care fields. 
Group practices  and managed care organizations  hire large numbers  of primary  care 
providers  to keep their costs down.  Compared  to most of the facilities  where  Corps 
providers  serve,  group practices  and managed care organizations  offer higher  salaries, 
fewer on-call assignments,  and better benefits.  Furthermore,  they are located  in more 
desirable  communities.  Recently,  managed care organizations  increased  salaries and 
financial  incentives,  such as fringe benefits  and improved  support  services,  to recruit  and 
retain primary  care providers.4 
At least half of the loan repayment  applicants  withdraw  their applications  because  they 
cannot  find an approved  facility that (1) has a current  vacancy,  (2) can support them 
financially  or professionally,  and/or  (3) they find attractive.  Fewer  than 43 percent  of the 
1,164 providers  who submitted  applications  and sought placements  in fiscal year  1993 
found a placement. 
NURSE  PRACTITIONERS,  PHYSICIAN  ASSISTANTS,  AND  CERTIFIED  NURSE 
MIDWIVES  FREQUENTLY  FACE  PRACTICE  BARRIERS 
Almost three-fourths  of nurse practitioners,  physician  assistants,  and certified  nurse 
midwives  reported  facing barriers  to providing  medical care.  The most commonly 
mentioned  barriers  are physicians  attitudes  and the lack of prescriptive  authority  and 
hospital admitting  privileges.  Several complained  about their inability  to receive  payment 
from Medicare  and Medicaid  for their services. 
Providers  offered  suggestions  on how to eliminate  these barriers.  Some suggested  that 
regional  offices act as problem-solving  resources  for providers  by knowing the State laws 
and by working  closely  with the professional  associations.  Others believe  PHS should 
teach facility administrators  and doctors  about the services  that these providers  are trained 
to perform  and the type of support they need.  The PHS staff agreed  that facility 
administrators  should be educated  better. 
3 Estimatebased  upon  data  from  (1) Third  Report  of the  Council  on Graduate  Medical  Education, 
October  1992;  (2) Health  Personnel  in the United  States.  Eighth  Report  to Con~ress.  1991,  September  1992; 
(3) the American  Osteopathic  Association;  (4) the Association  of American  Medical  Colleges;  (5) the 
American  College  of Obstetrics  and  Gynecology;  (6) the American  Dental  Association;  (7) the American 
Academy  of Physician  Assistants;  (8) the National  Organization  of Nurse  Practitioners;  and  (9) the American 
College  of Nurse  Midwives. 
4 Palsbo  and  Sullivan,  The  Recruitment  Experience  of Health  Maintenance  Orwmizations  for  Primary 
Care  Physicians,  The  Group  Health  Association  of America,  Inc.,  May  1993,  pp.  i and  11. 
12  Some facility  administrators  have changed their attitudes  and are  making better  use of 
nurse practitioners,  physician  assistants,  and certified  nurse midwives.  Because facilities 
must reduce  their overhead  and provide  care to more people,  they are realizing  the value 
of these providers.  One-third  of directors  seek more of these caregivers,  and some 
facilities  are striving to use them more effectively.  One facility is part of an innovative 
statewide pilot project  that utilizes nurse practitioners  in a system called  telemedicine. 
A nurse practitioner  serves  multiple counties in a fully equipped  mobile unit and keeps in 
direct contact  with primary  care and specialty physicians  through  the use of cellular 
phones,  video,  and computers. 
THE  CHECK  DISBURSEMENT  PROCESS  COULD  BE  JMPROVED 
More  than one-third  of loan repayers  and a few scholars described  problems  related  to 
financial disbursements  from PHS.  The most significant problems  involved  late checks 
and checks with incorrect  addresses,  names,  and/or  amounts.  Many providers  also 
reported  difficulty  when trying to rectify  the problems.  They  stated that they did not 
know whom to call,  had to call multiple times,  and received  inadequate  responses  from 
PHS. 
The regional  PHS staff echoed loan repayers  concerns  about the check distribution 
process.  Staff said check problems  undermine  their efforts  to build professional 
relationships  with providers  and unnecessarily  increases  their workload.  The Division  of 
Scholarships  and Loan Repayments  recently  instituted  a toll-free  number  to alleviate  the 
situation. 
13  RECOMMENDATIONS 
PHS  SHOULD  IMPROVE  ITS  COMMUNICATION  WITH  AND  SUPPORT  FOR 
PROVIDERS  AND  FACILITIES 
Providers,  directors,  and PHS staff believe  good communication,  adequate  support,  and 
outreach  are essential  to maintain and increase provider  morale and satisfaction.  To 
improve  communication  and strengthen  the Corps,  PHS should consider: 
	 exploring  new and creative  approaches,  such as (1) conducting  national  orientation 
of each years  new providers  and (2) providing  on-site  support for both providers 
and facilities; 
	 assigning  each provider  and facility a contact person  and establishing  a minimum 
level of contact; 
  increasing  outreach  and educational  activities  for all new and existing  facilities; 
	 increasing  technical  assistance  to facilities  about (1) the application, 
(2) recruitment  and retention  methods,  and (3) clinical  and management  practices; 
	 educating  facilities  about the value of nurse practitioners,  physician  assistants,  and 
certified  nurse midwives;  and 
	 assuring  that each provider  clearly  understands  and is fully aware  of all aspects of 
the Corps program  prior  to signing the contract. 
PHS  SHOULD  CONSIDER  MORE  FLEXIBLE  MATCHING  AND  PRACTICE 
POLICIES 
Providers,  directors,  and PHS staff believe increased  flexibility  would improve  retention 
and provide  better  solutions to the shortage of health care providers.  Among other things, 
PHS should consider: 
.  part-time  options with extended  repayment  periods, 
  deferments  or time off for continued  education,  and 
  more site choices. 
14  PHS  SHOULD  DEVELOP  MORE  ACCURATE,  COMPLETE,  AND  UP-TO-DATE 
VACANCY  LISTS 
Providers  and directors  complained  about the insufficient,  inaccurate,  and outdated 
information  available  for matching.  TO solve these deficiencies,  PHS should consider: 
	 developing  a matching information  system that can be continually  updated  (such as 
an on-line computer  system); 
  issuing quality assurance  reports  and descriptive  profiles  of facilities;  and 
. providing  facilities  with more information  about individual  providers,  such as their 
language  skills and outside interests. 
PHS  SHOULD  USE  DIRECT  DEPOSIT  TO PAY  PROVIDERS 
Participants  in the loan repayment  program  and a few scholars have difficulties  receiving 
their checks  on time and at the correct  address.  The PHS could alleviate  these problems 
and save money if it deposits payments  directly  into providers  accounts. 
AGENCY  COMMENTS 
In written  comments  on the draft report,  PHS concurred  fully or in part with all of the 
reports  recommendations  and described  the actions they have already  taken or plan to 
take.  The PHS expressed  concern  that the report  does not reflect  the program 
improvements  PHS has made since  1990, because  most of the providers  interviewed  were 
placed  under policies  developed  prior  to the 1990 legislation.  The PHS also included 
several  technical  comments.  The full text of PHS comments  appears  in Appendix  B. 
OIG  RESPONSE 
In response  to PHS comments  on the draft report,  we have made some technical

corrections.  We recognize  and support the numerous  improvements  that PHS has made

and plans to make to improve  communication  and support,  flexibility,  vacancy  list

accuracy,  and monetary  disbursement.  Although the majority  of the providers  we

interviewed  were placed  under policies  that were developed  prior  to the  1990 legislation,

more than two-thirds  of providers  interviewed  were still serving or not yet serving  their

obligations.  These providers  expressed  concerns  about communication  and support at the

time of our interview  in late  1992.  Their  concerns  are indicative  of current

communication  deficiencies  despite the fact that they were placed  under

pre-1990  policies.

15  APPENDIX  A

SAMPLE  SELECTION  METHODOLOGY,  ESTIMATES,  AND  CONFIDENCE 
INTERVALS 
Provider  Sample  Selection  Methodology 
We conducted  telephone  and in-person  interviews  with a random  sample of 302 Corps

providers  between  September  1992 and January  1993.  Working  from prepared  discussion

guides,  we asked providers  about their experiences  with the Corps recruitment,

placement,  and retention  efforts.  In order  to analyze the impact  of Corps policies  on

specific providers,  we seleeted our sample based on  13 separate  strata.  We based the

strata on the type of assistance  the provider  received  (scholarship,  loan repayment,  or

volunteer)  and the year in which the provider  was placed or received  the assistance  (1986,

1989, or  1991).  We established  two additional  strata to collect  the individual  experiences

of obstetrician/gynecologists,  nurse practitioners,  physician assistants,  and certified  nurse

midwives.  A discussion  of the strata follows:

	 Scholars--Awarded.  Scholars  may be awarded  their scholarship  up to 7 years 
before  they enter  the placement  process.  We selected  samples of 30 providers 
each from 3 different  years based on when the scholarship  was awarded.  We 
asked these providers  in greater  detail about their experiences  with Corps 
recruitment  efforts. 
	 Scholars--Placed.  To determine  the impact of changes  in placement  policies,  we 
selected  samples of 30 providers  each from 3 different  years based on when the 
scholar  was placed.  We asked these providers  in greater  detail about the level of 
assistance  they received  in finding a site, their satisfaction  with placement  choices, 
and how available  choices  met with their expectations. 
Volunteers.  Volunteers  are providers  who do not receive  financial assistance. 
b	
They want to practice  in underserved  areas and request  Corps assistance  in finding 
a facility.  We selected  samples of volunteer  providers.  We excluded  their 
responses  from our analysis,  however,  because  the PHS universe  was incomplete. 
	 Loan  Repayers.  Loan repayers  enter  the program  and are placed in the same 
year.  Since the loan repayment  program  was established  in  1987, we sampled 
30 providers  each from  1989 and  1991. 
	 Obstetricians.  Due to the need for obstetric  services  in certain  underserved  areas, 
PHS officials and health care professionals  told us that obstetricians  face greater 
hardships  than other Corps providers.  To determine  if this was true,  we selected a 
separate  sample  of  all  10 obstetricians  who were placed  in 1991. 
A-1  E  Nurse  Practitioners,  Physician  Assistants,  and  Certified  Nurse  Midwives. 
These providers  may be hindered  in their practice  of medicine by current  laws, 
regulations,  and practice  policies.  We sampled the 44 nurse practitioners, 
physician  assistants,  and certified  nurse midwives who entered  the Corps in 1991. 
We could not interview  all sampled providers  because  some (1) had reloeated,  (2) refused 
to participate,  (3) were involved in cases that were being reviewed  by the Department  of 
Justice,  or (4) had not completed  their medical training.  In addition,  we interviewed 
three providers  twice based on their being awarded  a scholarship  in one year and placed in 
another.  The following  chart  summarizes  the interviews  that we conducted: 
1986  1989  1991  ml 
Scholars--Awarded  29  29  30  88 
Scholars--Placed  26  29  30  85 
Volunteers  6  6  10  22 
Loan Repayers  NA  30  30  60 
Obstetricians  NA  NA  9  9 
Nurse  Practitioners,  Physician  Assistants, 
and Certified  Nurse Midwives  NA  NA  41  41 
Upon completion  of the interviews,  we coded all provider  responses  and entered  the data 
into a computerized  database.  Within each stratum,  we weighted  each providers 
responses  based on his/her  representation  of an equal share of the universe. 
Etimates and confidence  intervals 
The chart below  summarizes  the estimated  proportions  and the 95 percent  confidence 
intervals  for the statistics presented  in the report. 
statistic 
I 
Point  Estimate  95%  Confidence  Interval 
Proportion  of directors  who  believe  their  facilities  could  not  adequately  serve  patients  without  Corps 
providers 
I I 
I 
90.0%  79.3% - 100% 
I 
Proportion  of directors  who  say they  need  at least  one  more  provider  to offer  adequate  health  care 
I # 
I 
80.0%  65.7% - 94.3% 
A-2  statistic 
I 
Point  Estimate  95%  Confidence  Interval 
I 
Proportion  of directors  who  believe  they  will  always  need  the  Corps  to recruit  providers 
I  66.7%  I  49.8%  - 83.5% 
Proportion  of loan  repayers  who  say  they  would  have  worked  at the  facility  even  if they  had  not 
received  loan  repayment 
I  59.5%  I  50.8%  - 68.2% 
Proportion  of those  loan  repayers  who  would  have  worked  at the facility  without  loan  repayment  who  do 
not plan  to stay  at the  facility  just  because  of loan  repayment 
I  67.7 %  I  55.7%  - 79.6% 
Proportion  of providers  who  called  PHS  with  questions  who  claim  that  PHS  staff  are  not  responsive  to 
their  needs 
I  35.7%  I  23.0%  - 48.3% 
Proportion  of providers  who  recall  no conbct  with  PHS 
I  27.1%  I  17.2%  -37.1  % 
P roportion  of scholars  placed  in 1991 who  believe  PHS  does  not contact  them  often  enough 
I  56.2%  I  44.0%  - 68.3% 
Pr oportion  of loan  repayers  placed  in  1991 who  believe  PHS  does  not contact  them  often  enough 
I  41.9%  I  30.2%  - 53.7% 
Pr oportion  of directors  who  did not know  that PHS provid~  twkiml  assisti~ 
I 
I  26.7%  10.8%  - 42.5% 
Pro portion  of directors  who  recall  being  offerd  technical  assistance  by regional  offices 
1 I 
I  30.0% 
I  13.6% - 46.4% 
Proportion  of directors  who  had  no interaction  with  primary  care  associations  and  State  agencies 
I  30.0%  I  13.6% - 46.4% 
Proportion  of directors  who  believe  the application  process  is burdensome 
I  48.3%  I  30.1 % - 66.5% 
Proportion  of directors  who  were  dissatisfied  with  the matching  process 
I  33.3%  I  16.5%  - 50.2% 
Proportion  of those  providers  who  participate  in the matching  process  who  were  dissatisfied  with  the 
number  and  variety  of facilities  available 
I  1 
u  I  60.6%  I 
48.9%  - 72.4% 
u 
A-3  Statistic 
Point  Estimate  95%  Confidence  Interval 
I  I 
Proportion  of scholars  placed  in 1991 who  were  dissatisfied  with  the  matching  process 
I 
70.4%  59.2%  - 81.6% 
Proportion  of providers  who  had  a problem  who  attribute  it to the matching  process 
60.2%  48.5%  - 71.8% 
I 
Proportion  of providers  who  believe  that PHS  does  not adequately  describe  the matching  process  and  the 
facilities  available  for placement 
I 
29.1%  20.7%  - 37.4% 
Proportion  of providers  matched  to a facility  who  expected  the HPOL  or the loan  repayment  vacancy  list 
to contain  more  facilities  nationally  or in specific  areas 
28.1 %  18.4%  - 37.8% 
I 
Proportion  of  1991  scholarship  recipients  who  say PI-IS providd  information  on available  facilities  and 
how  the  list is made 
76.7%  62.1%  - 91.3% 
I 
Proportion  of  1989 scholarship  recipients  who  say PHS  provided  information  on available  facilities  and 
how  the  list is made 
75.9 %  67.3%  -84.49$ 
I 
Proportion  of  1986 scholarship  recipients  who  say PHS  provided  information  on available  facilities  and 
how  the list is made 
38.5%  28.5%  - 48.5% 
Proportion  of providers  placed  in 1991 who  recall  receiving  only  the list and  no further  assistance 
52.1 %  43.0%  - 61.2% 
Proportion  of directors  who  believe  the information  on the HPOL  and  loan  repayment  vacancy  list is 
inadequate  and  that  providers  do not  get a good  picture  of facilities 
I 
20.0%  5.7%  - 34.3% 
Proportion  of providers  who  stay  at facilities  more  than  a year  after  they  complete  their  obligation 
37.9%  21.4%  - 54.5% 
Proportion  of loan  repayers  who  stayed  at their  facility  after  they  completed  their  obligation 
49.4%  33.7%  - 66.3% 
Proportion  of scholars  who  stayed  at their  facility  after  they  completed  their  obligation 
47.1%  31.0%  - 63.4% 
I  I 
Proportion  of loan  repayers  who  plan  to stay  at the  facility  after  they  complete  their  obligation 
I 
50.5 %  38.8%  - 61.7% 
A-4  statistic 
I  I 
Point  Estimate  95%  Confidence  Interval 
Proportion  of scholars  who have started serving  their obligation  who  plan to stay at the facility  after they 
complete  the obligation 
1 I 
I 
18.9%  8.4%  - 28.9% 
I 
Proportion  of providers  placed  in rural  areas  who  stayed  or plan  to stay  at the  facility  atler  they 
complete  their  obligation 
39.7%  28.8%  - 50.8% 
(90%  Confidence) 
Proportion  of providers  placed  in urban  areas  who  stayed  or plan  to stay  at the  facility  after  they 
mmplete  their  obligation 
18.6%  10.6%  - 26.4% 
(90%  Confidence) 
Proportion  of directors  who  believe  their  retention  role  is to offer  attractive  work  environments 
63.3%  46.1%  - 80.6% 
Proportion  of providers  who  believe  adequate  compensation  is crucial  to retention 
44.6%  37.0%  - 52.2% 
Proportion  of directors  who  believe  adequate  compensation  is crucial  to retention 
80.0%  65.7%  - 94.3% 
I 
Proportion  of directors  who  agree  professional  support  is essential  to clinical  success  and  retention 
23.3%  8.2%  - 38.5% 
Proportion  of providers  who  cite  problems  with  inflexible  policies  or suggest  more  flexible  policies 
51.7%  43.7%  - 59.8% 
Proportion  of those  providers  who  attempted  to transfer  who  experienced  difficulties 
24.8%  13.8%  - 35.6% 
I 
Proportion  of nurse  practitioners,  physician  assistants,  and  certified  nurse  midwives  who  reported  facing 
barriers  to providing  medical  care 
I 
71.1%  67.1%  - 75.0% 
Proportion  of directors  who  seek  more  nurse  practitioners,  physician  assistants,  and  certified  nurse 
midwives 
36.7%  19.4%  - 53.9% 
I  I 
Proportion  of loan  repayers  who  described  problems  with  financial  disbursements  from  PHS 
33.5%  24.7% - 42.3% 
I  I 
A-5 
_  APPENDIX  B 
PHS  COMMENTS 
#/ - +. 
j$  DEPARTMENTOFmTH  &HUhWNSERVICES  Wbk He@MSI?IVIC8 
: 
: 
%>  20SS7 
RockvdbMO 
W?14@4 
@nm?ARntQl

Fxolu:
  Zu3siszancSecretary for Health 
Subject:	 Office of Insmctor General 10IG) Draft ReDOSt 
NationalHeaith Semite  CLX&S: A Survey ;f 
Providers, Facilities,and Staff, cIEI-O9-91-O131O 
To:  Inspector General, OS

Attached are the Public Health Semite  comments on the subject 
draft report.  We concur  fully or in ~  with all of the 
reports recommendations and our c~  es describe the actions

we have taken os Plan to take to imlwmnt  them.  We have also

included several iechncal comments-foryour consideration.

/4

Attachment

B-1  PUBLIC  TH SERVIC z  (PHs\  co~s  oN  THEO  FVIc~  OF 
I~sp~cToR  GENEWU  (oIG)  DUV  REpoR~  .NATIoN~  g~~ 
s~c- ?? co RPS:  A  0? PROVIDER  TV  AND SThFY. 
.&91+13&JJ=J5 
QEI
The repo-n examined the Health Resources and Serrices

AdministrationsNationalHealth Se~ice  Corps (NHSC)

placement cycles for Fiscal Years 1986,  1989,  and  1991. 
Although these placementswere made over a five year span, all 
=horts  szudiadby the OIG were placed ~der  policies 
consistent with the previous (pre-1990)-C  legislation. 
This is impomt  to stress because all of  the  areas  of 
concern  expressed  in  this  OIG  repo~  regamng  the coho=s  of 
1986,  1989,  and  1991 were recognizedby the program 
administratorsand correctiveplans  were  implemented to 
-e  the zm5c.

Significantpositive changes in  program Grertion, management 
and wersight have occxtxed in the last 4 1/2 years heg~g 
with  program input into legislativechanges resulting in a new 
law, the NHSC RevitalizationAmendments of  1990  (Public  Law 
101-597).  Sn  addition,  new  leadershipm  ms  Bureau of 
Primary Care, Divisionof National Health Sdce  Corps, and 
I)ivision  of  Scholarshipsand Loan Repayments (DSLR),and a 
staff reorganizationin both divisionshave improved program

management  and focusedthe organizationto better meet the

needs of the medicallyundeserved populations.

It is impomant to recognize,however, that changes in program

adminiswation may take sweral years to be realized in terms

of impact on providersin the field and on retention.  The 
scholarship  p~,  in  particular, spm  an average of  nine 
~  for  P~Ysicims and foa= years for other providers from 
@tial  award to completionof semice.  Substantial progress 
has been made in ~rwing  the  overall operation of the NHSC. 
-les  of the ~rovments  are  indicazed in our responses to 
the OIG*S reconnaendations.The NHSC staff continuously 
listens to its  customers,undersexed people and communities, 
and pximary care providers, and adjusts its policy to  betzer 
serve  those  mosz in  need of primary care semices. 
91G  Recommendution 
1.	 The PBS should iqrove  its coxmwcation  wi-A  and support 
for providersand facilities. 
We concur and note that the NHSC has already taken and will 
continue to take  significant ac=ions to improve the levels of 
B-2
 2 
communicationand suppo.-.to providezsand facilities.  Early

and  cmtinuing  contact is one of the new- NHSCS main  goals.

Therefore, the NIiSCis continuallyexamining its amrketig  and

recruiting effo.-.sto  assure that info~zion  p~ded  abou%

the  programs  is m~enx  and accurate,-d  eval~ting ways to

Lsprove interactionwith studentsin training and providers in

the field.  Program  managers are in the process of

stmdardizing  the technicalassistanceand wersight

activities  that  ase  prwided through the PRS Regional Offices,

cooperativeagreements,primazy care associations and

cfsntractors.

The NHSC has designed and implementedstrategies to

Communicateprogram requirementsand benefits to new providers

and facilities,and to prospectiveproviders.  This spring the

lU3SCwill conduct the fo~  round of intividml  intmiews

for all scholars. The scholarswill be provided with detailed

izaformationabout the nature and requirements  of  NiiSCsemice, 
financial and se.~ice obligations,the site selectionprocess, 
and a sampling of currentNHSC sites.  In addition,  for the 
past  three  years the NHSC has been conducting annual 
oriermation seminars for new scholars and providers on a 
nationwide basis.  The PES Regional Offices ham  been an 
integral part of these orien~tion activities. Finallyt at

least annually -de NESC conductsconferenceswith new

providers including scholars,loan repayers, volunteers,  end

non-obligatedprovidersseiningthrough the WC.

The NHSC has implementedproceduresto  ensure  continuing 
contact with prwide.~ once they are on site.  Providexs are 
being advised of whom they need to contact with respect to 
different guestions or problems. Since the nature of the 
providersquestAonsand concernswill varg depending upon 
whether they are still in school,beginning semice,  or 
seeking  continuingprofessionaleducation, the program is 
working to  assure  that each provider knows the first point of 
contact during all stages of  the  relationshipwith the NESC. 
XIIaddition, the NKSC continuesto mrk  with sites to assure

that providers have salary and benefit packages comparable

with their peers in the c~  ty, and has provided clixQcal 
suppo~. funding  and locum tenens support which offer providers 
~~.unities  to  pursue educationalactivities on and off-
site.  When new providessare placed  at  a  site they are 
encouraged co serve at Least one year before transfening  to a 
new site.  The initialplacementis the result of a documented 
need for  prima.= care se--icesin that conmunity. The NliSCis 
concernedabouz continuityof care, and the impact on  the 
C~ity  of the 10SS of  a new pravider through a transfer. 
When it is not possible for boti size and provide: to resolve 
tieix  differences,transfe:to another needy comnmity  is 
B-3  3 
facilitated.  Providerswho  defaultan the~- service 
obligation incur financialdaaqes under the statuxory fo~a 
of three times printipal plus intezest,less any credit 
prorated for  actual semice. 
The NESCS technical assistanceactivitj.esaddress the

application process, recruitment,retem~on,  c~cal  and

management practices. With respect to *e  nurse praCEitiOnerS

(NPs), physician assis~ts  (Ph), and cetified nurse

midtives (CNMs),we are wrkiag with tie PHS Regional Offices,

State associations and professionalorgtizations to educate

everyone involved on the team approach eo pr~  care, the

full utilization of all primary care health professionals,  and 
how  to  reduce practicebarriers. 
91G Recommendation 
2. The PIIS  should considermare flexible matching and 
practice policies. 
We concur witi the general  thrust of  us  re~endation,  but 
recogxize  that  the programmust operste  within stauxoq 
l~tations.  The programhas made many positive eff~  to 
increase the flexibilityof the matching process, tie

assuring that the primarymission of serring those most  in 
need is ~tained.  The programnow has expanded the number 
Of vacancies availableper scholar,as compued with earlier 
Cohom  , and has increasedthe number of  vacancies  available 
for  providers interestedin loan repayment. 
Howwer,  the number of  choicesavailable to scholars is 
prwided  for by  statute: h  Vacancies  for  each  scholar  in 
a  given  discipline  andjor  specialtY,  up  to a maximum of  500 
vacancies.  Far example,  if thereare 10 pediatricians 
amilable  for semice, the Health ProfessionalsOpportunity 
List (HPOL) for that groupwuld  contain 30 sites (10 times 
3).  15  there  are  15  family  nurse  practitionersavailable, 
there would be 45 sites on the list.  The program provLdes 
Scholarship recipientswith the appropriate~OL  for their 
specialty while they are stillin train$ng, one year prior to 
their targeted servicedate. 
Recognizing that there are frequently  mOZS vacancies of 
highesz need &an wuld  be permitzed~  the 3 co 1 szatutory 
limit, the program began to collectplacement preferences of 
SchOIGs using the PrafesslonalTraining Information 
Questionnaire (PTIQ), co be used far consideration in the

development of de HPOL. This will be the third year in which

the PTIQ is used to selecthighp=iarity sites *&at may more

B-4

  4

closely meet providerspreferences. This p~ts  the program 
to  meet  0%- pzimary  mission,se.~ingpeople of  greaZest need, 
while considering  Ae  needs  of our other imporcam  customers, 
prima.rrcare psoviders. 
During the early decisionalternative(EDA)phase of  the 
placement  cycle,  provides have approximatelynine months to 
choose  a site from  the  HPOL that will best meet their persomal 
and professional needs. It is only after the EDA, when a 
sChOIU  has not chosen  a site, that the program assigns the 
individual to a high prioritysite,as ~  by law. 
Ovex B5 percent of providersare hired by individual conumanity

organizations.  The communities receive notification that they

have been placed on the vacancylist at the beginning of the

placement cycle.  The communities know thaz they have a one-in

three chance of recmiting an NIISCscholar, since there are

three times as many vacanciesas scholars. As the hiring 
authority, they are recruiting  scholL-s  as  well  as  others  who 
may wish to senre in theircommunities. As a result, some 
sites will fill  theL  vacancieswith providers other than NESC 
schola~s.  For  this  reason,scholarsare encouraged to pursue 
theti options as soon as they get the HPOL.  NESCs gOal is to 
help fill  all  of  the  vacanciesin the neediest c~ties, 
while matching all obligatedscholars. 
The program has continuedto expand the n~ez  of sites that 
axe available through loan repayment,  enhanctig  eff orta  to 
target  communities of greatestneed.  For the last three 
years, there  have  been approtitely  t&ee  vacancies available 
for each NKSC loan repaymentcontract. LOan repayment 
applicants are not obligateduntil they match to  a site end 
have a loan repaymentcontractapprovedby DSU1.  While loan 
repayment sites may be less needy than scholar sites, they are 
still in underserved communities and may be less ideal- than 
many candidates  would prefer. Loan repayers may also  match to 
HPOL sites. 
The loan rapayment programis an importantretention and 
recruiumnt  program. Many providers,who are already on sixe 
view loan repayment as the  carrot  that will entice them to 
 
stay.  In addition, the loan repayment  program has been a 
significant recruitingtool for NliSCsemice.  Loan repayers 
have already made a conmitmenc to primary care by virtue of 
their chosen discipline. The loan repaymenx program has, in 
most cases,  providedtie incenzivethat was  needed  to  attract 
these  provide=s co underservedareas.  The retention rate for 
loan repaye=s is about double that of schol&-s.  msed  on data 
fmm  focus groups, the NHSC believes chat loan repayment is a 
c=itical considerationin site selec=ion. Once on-site, 
providezs become incegzatedinto the community, which is a

B-5
 5

c=icical facmx  in any decision to  r~in  be~nd  an obligation 
period. 
The OIG reports characterizationof the scholarship and loan

repayment programs as being resperdvely more competitive and

less r%gorous  does both programsa dissmice.  The progrmns 
are comphmsmary.  In the case of  schoIL-s,  the  application 
and interriew process ameuupts to  ass~e  that the stridenthas 
a clear understandingof what embarkingon a career ixIp= 
care se-ice  in undersenmd  arwas  means,  and  whaz  tbe 
obligation helshe is about to incur smalls.  The scholar will 
bcur  the obligationseveralyears prior to completing his/her 
education and beginningse~ice.  In the case of loan 
repeyers, they are not obligateduntil they match to a site

and sign an agr~nt  with DS4.

The  NESC has noted a progressivein~ase  in retention rates 
over the last few years.  Of  the  universe  of  scholars  and  loan 
repeyers  who have  completedtheir obligations,increasing 
numbers have agreed to continue s-ice  to the unders~ed 
beyond their obligationperiod at their current site:  39

percent in =  1991, 52 percent izIPY 1992, and 58 percent in

FY 1993.  Zn FY 1993, of  the  58  percent  which  were  retained, 
43  percent of the scholarsand 73 parcmt of the loan repa~s 
stayed on at theix site afte:  completig  their  obligation. 
There -re  others  who were  re~ed  in smite  to the 
 
undersezwed, moving into anothm- underse~  coxnunity, taking 
a public  health position,or teachingprimary care h  an 
academic set-~g. 
The way in which providersare treated,or perceive to be 
treated, by the programs in  which  they  are  seining  is crncial 
to  rexention. Improving employerqioyee  relationships is 
critical in any professicm. The NRSC is taking steps to 
prepare providersand commnity orgmzations  to facilitate 
retention, and will delete sites from  tie  vacancy  lists  which 
routinely do not manage theix practices appropriately. 
The  statutemandates fuU-time clinicalpractice. The intent 
 
was based on the belief that underse~  communities ~ 
full-time  providersto improve the health of the c~  v 
Any change to the r~ent  would necessitate a change in 
legislation. Full-timepractice is defined as a minimum of 
45 weeks a year in practice. Obligatedproviders are 
permitted up to  7 weeks a year off-sitefor vacazion,  sick 
leave,  andtor  continuing  professional  education.  The  NIiSC  has 
provided  more  than  S1  million  annually  for  continuing 
professionaleducationfox the last severalyears.  Deferments 
are provided for residency~-aining,and all NESC providezs 
are now requiredby statuze to  be  fully qualified in theiz 
professional specialtybefore they stazx sezzice. 
B-6 
  6 
_in9  1993 the NESC matched 193 schol~s  and placed 477 loan 
repq yers.  In addition, 406 scholeships were  a~ed. 
NHsc  ea~C4  its site develo~mt  conmam  and other ongTohheg
. .
zem~l  assismce  efiom  to impmve  the matmg  process 
in future placmt  cycles,  while  rema*g  true  to  the 
mission of se~ing  those most  in  need. 
The OIG re~m  notes that p=  a~l~  o~y  a ml  n- of

providers to exercise the private pra~ce  option (PPO). The

reason that there are not more PPO sites is that HESC

prov>de.% generallywork in areaswhich cannot carrently

suppoxz an econ~cally  viablepractice.

miss+on to  locate prx~  care pmidm  fiI tm aiss  thweh NeRrSeC otSh
 ~ 
prozuciershave chosen not to go, and where healti care 
s-ices  would not otherwisebe availble. 
as a surprise  to  provide= to fiad that the cI t should not come

wMch  they are se=ing  are frequentlyeconomicOtIilmy uniatnide sin
educationally disadvantigti. 
it  at~-ae. pr~H owevCearX,S t phmei NdXeS~C  bewlhioe vweasn tt hatto 
can  continue  to 
m  whm  they are most needed  to se~e  wh~e  ~q  ~  -y 
make a difference. 
AS noted in Our coaanentsto recmendation  n- 1 abwe, 
NPs, Phe, and CNMs frequentlyface  lic~, 
acceptance, and site pratice ~m.  The ~=~~g

*th  professionalorgmzatiom,  States and State licensing

btmrds, and =
~ties  to remove  these  Prtwttce  barriers  and

allow for  the  ftil utilizationof  these  healti Providem  as

members of  intetisc~pltiq  practice teams.

working with PIE Regional Officesand primary cTahree NESC is also

associations to ensw  that all pmidm  are placed

situations where they can prac-ticethe full scope of in

professions.  their

OIG Reconunendatoin


3.	 The PHs should develop more ac~ate,  complete, 
to-date  vaca.xq lists.  and up-
PHS COnunent

We Concur.  The NHSC has improvtiand till contiue to ~~ 
the vacanq  list  developenz  and u+atig  process. 
NXSC recruitersin the field are ustig  laptop  cqtersCurrteon
tly,
access informationin a c

~ty  profile progrmn.

The NHSC continuesto enhancethe c~uterization  of vacancy

liszs to enswe  that they are as up-to-date as possible.  It 
i$ phmning  to provide descziptLveprofiles of  sizes which 
would not only desc:ibe the communiq, but also reflect the 
staffing and system of c~-e in that site. 
The NHSC is also

B-7  7

exploring  alternative  ways to  have  profiles of scholars

available to sites to assisz them in the matching process.  On

a pilot basis, the N?ISCis lookingat developingan on-line,

continuously updated file of available,eligible facilities.

The basis for these improvemmt~  ia  to assure  that  all

Cusxomezs  of NRSCS services  are  as  infomed  as  possfile

regarding vacancy data.  The better infozmazion  potential

providers  and sites have prior to  the  beg~  g  of  the  site

selection process, the more successfulthe mazch.  T5e program

welcomes additional suggestionsfor ~mving  customer

satisfaction.

UG  Recomnendation

4.  The PHS should use  direct  deposit  to  pay providers. 
PRs Conlment

We concur and, as noted at  the  etit  conferencewith staff from 
OIG, actions have already been taken to address this issue. 
For  NHSC scholars,  the  DSLR has the fiduciary responsibility 
for the allocation of  funds  to  pay  schools  for  tuition  and 
fees,  and  stipends for students. The M  Division of Fiscal 
Services handles the actual payments for the tuStion and fees 
to educational institutionsupon receipt and ve=ificatioa of 
invoices.  The PES Divisionof CommissionedPersonnel 
processes  the  monthly stipendsfor students.  A test  program 
to implement direct deposit of stipend checks is mzrently 
under development.  It is expectedthat tMs  system will be 
fully implemented in the firsthalf of  1994. 
Concerning loan repayments,DSLR prepares computerizedpayment

work sheets that account for what is due to each participant

at the point of contractbetween the -C  and the participant.

These work sheets include informationon the loan repayment

amount, appropriate interest,and tax payments.  The Division

of Fiscal Sexwices handles the actual disbursements. These 
procedures have resulted in a better  accuracy  rate  in  loan 
repaymexxs  than  ever  experienced  ~fore. 
It  is  the  programs experiencethat  most  complaints from 
providers about not receivingpayments can be ~aced to the 
providers failure  to  repmx  their  correct  address  to  the 
program.  In nearly all cases of payment complaintsreviewed 
by the program  staff,  the checkv&- not delivered because of 
an incorretn or  old addressand had been retuzmed  to  the 
Treasury Deparzaaent. 
The NHSC believes that it has taken appropriate actions to 
assure accurate and timely payments to  loan  repaynem  program 
B-8
 . . 
8

~cipanzs.  Hovever,they will continue to seek be=%er and 
more  accurate methods of payment. 
~ 
F-e  1.  th~ 
To present a more completepicture,  we suggest  that th$s 
mmPh  mention tie sho=ge  of primary care providers. 
2aae  2.  fir  st  naraaranh 
This paragraph does not fully recognizethe impo~t

contributions that NPs, PM., and CNHs make as a part of tbe

pdmary  care interdisciplinaryteam.  Indeed, individuals in

these disciplines are the providers of  choice in some 
cmmnnicies. 
~aae 2.  *p.o~~  Ovezsig  ht  fk~t  paraaradl 
The Office  of  StateActivitiesis not a formalized 
organizational unit in HRSAS Boreau  of  PAmazy  Health  Care 
and  does  not have any responsibilityfor NHSC activities. 
?aae 3*  f-={  t  mra  arauh 
WMle  PHS  is  required  to place those with a scholarship 
obligation, each individualis given a tie  month period  in 
Whitb  to  select  a  size  from  the  Eaalth  Professionals 
opportunity  List  which  has  been  approved  for  NHSC assignment. 
These individuals then negotiazewith the site facilities over 
possible assignment. If  an  obligatedscholar fails  to  find  a 
site during this nine month period, he/she is then assigned  to 
a site. 
paae 5.  irst Baraarmh 
The NESC makes concertedefforts  to  ensure  that providers and 
factiities get startedon the right foot.  The first year at 
the site is the most criticalin that regard.  We provide 
orientation sessions  for new providers,and are expnding 
effo~s  zo assure that field assignees!mw  who their first 
contact is for  questions  or  concezm. 
Paae  7, Zi=st sentences  of  the first and second uaraaranh s 
These statements confusethe older pm~m  md  cohorts studied 
by he OIG,  from che currenteffoms  of the revitalized NHS&. 
Increasing contac: with field provide.% is one  of  the 
cornerstones  of the newNIISC. 
B-9
 .  . . 
P-=  8,  second Daraar?@ 
We agree that  NESC expansionwill require -== 
Communication and coordinationamong PES components and have 
taken some s@nifLcant steps  to ~rove  commuxdcation and 
coo~tion.  Through work  planaingprocesses, the NESC is 
CIUIY  defining responsibilitiesas NESC expansion efforts 
are nnde-en.  Pmgrsm  officialsare examkin gwaysto 
econtx&ize,sueamlbe  and target  our  res~es  through 
impming  our daza and inforznationsystems, and s~llfying

repotig  ~ts.  While new resourcas may be needed to

handle a major expansion of the NESC, we believe that current

resources can be used more efficiently.

Paae 9~ second  ~araarau~ 
Efforts  are  underway  ia  the  NESC to  improve  the  percentage  of

facility directors who are satisfiedwith the completeness and

accuracy  of  iafomation  concerning  U  facilities  that is

contained  h  the  EPoL  and  loan  repagmentVaCaacy list.  our

cozments on the OIG reports~dations  discuss act$ons

taken or planned  m  provide  zIore ac~ze  and  timely

information  to  both  prmidara  and  facilities.

B-10