Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

NATIONAL HEALTH SERVICE CORPS: 

A SURVEY OF PROVIDERS, FACILITIES, 

AND STAFF 

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JUNE GIBBS BROWN 

Inspector General 

APRIL 1994 

OEI-O9-91-O131O 

I 
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 

inspectionsconducted by three OIG operating components: the OffIce of Audit Services, the 

OffIce of Investigations, and the OffIceof Evaluation and Inspections. The OIG also informsthe 

Secretary of HHS of program and managementproblems and recommends coursesto correct them. 

OFFICE OF AUDIT SERVICES 

The OIG’SOftlce of Audit Services(OAS)provides all auditing servicesfor HHS, either by 

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 respective responsibilitiesand 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 OIG’SOftlce of Investigations(01) conducts criminal, civil, and administrative investigations 

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 OIG’SOffice of Evaluation and Inspections (OEI) conducts short-term management and 

program evaluations(called inspections)that focus on issues of concern to 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 departmental programs. This report was prepared in the San Francisco regional 

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, 

AND STAFF 

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OEI-O9-91-O131O 

I 
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 

communicti”on 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 

report’s 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


� pHS’and facilities’roles in retention . . . . . .. O.. O.O . . . . . . . .00.0...9


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


.~anrepaymentprogram expansio n . . . . . . . . . . . . . . . . . . . . . . . . . . . 11


� practice barriers ..., . . . . . . . . . . . . . . . . . ... D O . . . . . . . . . . . . .0 12


•ch~kdisbursement... . . . . . . . . . .. OO.O.. . . . . . . . . . . . . . . . . . . 13


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 public’s 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 program’s 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 provider’s placement there would result in a long-term solution to a 

community’s 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. 

P	 Volunteer VacancyList: Many sites meet the minimum criteria for Corps 

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.tz”ons? 

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 obligti”ons? 

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 questz”onsor 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 

exiti”ng 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.h”on 

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 facility’s 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 community’s 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 year’s 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 

report’s 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. 

b	 Volunteers. Volunteers are providers who do not receive financial assistance. 

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 provider’s 

responses based on his/her representation of an equal share of the universe. 

Eti”mates and confidence intervals 

The chart below summarizes the estimated proportions and the 95 percent confidence 

intervals for the statistics presented in the report. 

statistic 

Point Estimate I 95% Confidence Interval 

Proportion of directors who believe their facilities could not adequately serve patients without Corps 

providers 

I I 

I 90.0% I 79.3% - 100% 

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 

I 95% Confidence Interval 

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 26.7% I 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 

I Point Estimate I 95% Confidence Interval 

Proportion of scholars placed in 1991 who were dissatisfied with the matching process 

70.4% I 59.2% - 81.6% 

Proportion of providers who had a problem who attribute it to the matching process 

I 60.2% 48.5% - 71.8% 

Proportion of providers who believe that PHS does not adequately describe the matching process and the 

facilities available for placement 

29.1% I 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 

I 28.1 % 18.4% - 37.8% 

Proportion of 1991 scholarship recipients who say PI-IS providd information on available facilities and 

how the list is made 

76.7% I 62.1% - 91.3% 

Proportion of 1989 scholarship recipients who say PHS provided information on available facilities and 

how the list is made 

75.9 % I 67.3% -84.49$ 

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 

I 47.1% I 31.0% - 63.4% 

Proportion of loan repayers who plan to stay at the facility after they complete their obligation 

50.5 % I 38.8% - 61.7% 

A-4 
statistic 

I Point Estimate I 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% I 8.4% - 28.9% 

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% I 65.7% - 94.3% 

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% I 13.8% - 35.6% 

Proportion of nurse practitioners, physician assistants, and certified nurse midwives who reported facing 

barriers to providing medical care 

71.1% I 67.1% - 75.0% 

Proportion of directors who seek more nurse practitioners, physician assistants, and certified nurse 

midwives 

I 36.7% I 19.4% - 53.9% 

Proportion of loan repayers who described problems with financial disbursements from PHS 

I 33.5% I 24.7% - 42.3% 

A-5 

———_ 
APPENDIX B 

PHS COMMENTS 

#/ -’ +. 

: DEPARTMENTOFmTH &HUhWNSERVICES Wbk He@MSI?IVIC8 

: 

j’”$ ‘“%> RockvdbMO 20SS7 

W?14@4 

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Fxolu
: Zu3siszancSecretary for Health 

Subject:	 Office of Insmctor General 10IG) Draft ReDOSt 

“National Heaith 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 

report’s recommendations and our c~ es describe the actions
 we have taken os Plan to take to imlwmnt them. We have also


included several iechn”cal comments-for your 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. 

QEI.&91+13&JJ=J5 

The repo-n examined the Health Resources and Serrices


Administration’s National Health Se~ice Corps (NHSC)


placement cycles for Fiscal Years 1986, 1989, and 1991. 

Although these placements were made over a five year span, all 

=horts szudiad by 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 recognized by the program 

administrators and corrective plans were implemented to 

-e the zm5c.


Significant positive changes in program Grertion, management 

and wersight have occxtxed in the last 4 1/2 years heg~g 

with program input into legislative changes resulting in a new 

law, the NHSC RevitalizationAmendments of 1990 (Public Law 

101-597). Sn addition, new leadership m m’s Bureau of 

Primary Care, Division of National Health Sdce Corps, and 

I)ivision of Scholarshipsand Loan Repayments (DSLR), and a 

staff reorganizationin both divisions have improved program


management and focused the organization to better meet the


needs of the medically undeserved populations.


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


adminiswation may take sweral years to be realized in terms


of impact on providers in 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 completion of 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 providers and 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 

communication and suppo.-.to providezs and facilities. Early


and cmtinuing contact is one of the “new- NHSC’S 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 interaction with students in training and providers in


the field. Program managers are in the process of


stmdardizing the technical assistance and wersight


activities that ase prwided through the PRS Regional Offices,


cooperative agreements, primazy care associations and


cfsntractors.


The NHSC has designed and implemented strategies to


Communicate program 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 scholars will be provided with detailed


izaformationabout the nature and requirements of NiiSCsemice, 

financial and se.~ice obligations,the site selection process, 

and a sampling of current NHSC 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 conducts conferences with new
 providers including scholars, loan repayers, volunteers, end


non-obligated providers seining through the WC.


The NHSC has implemented procedures to 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 

provider’s questAons and concerns will varg depending upon 

whether they are still in school, beginning semice, or 

seeking continuing professionaleducation, the program is 

working to assure that each provider knows the first point of 

contact during all stages of the relationship with 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 educational activities on and offsite. When new providess are placed at a site they are encouraged co serve at Least one year before transfening to a new site. The initial placement is the result of a documented 

need for prima.= care se--ices in that conmunity. The NliSCis 

concerned abouz continuity of 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. Providers who default an the~- service 

obligation incur financialdaaqes under the statuxory fo~a 

of three times printipal plus intezest, less any credit 

prorated for actual semice. 

The NESC’S 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 practice barriers. 

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 program must operste within stauxoq 

l~tations. The program has made many positive eff~ to 

increase the flexibility of the matching process, tie


assuring that the primary mission of serring those most in 

need is ~tained. The program now has expanded the number 

Of vacancies available per scholar,as compued with earlier 

Cohom , and has increasedthe number of vacancies available 

for providers interested in loan repayment. 

Howwer, the number of choices available 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 there are 10 pediatricians 

amilable for semice, the Health Professionals Opportunity 

List (HPOL) for that group wuld contain 30 sites (10 times 

3). 15 there are 15 family nurse practitioners available, 

there would be 45 sites on the list. The program provLdes 

Scholarship recipients with the appropriate ~OL for their 

specialty while they are still in train$ng, one year prior to 

their targeted service date. 

Recognizing that there are frequently mOZS vacancies of 

highesz need “&an wuld be permitzed ~ the 3 co 1 szatutory 

limit, the program began to collect placement preferences of 

SchOIG”s 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 select high p=iarity sites *&at may more


B-4


— 
4


closely meet providers’ preferences. This p~ts the program 

to meet 0%- pzimary mission, se.~ing people of greaZest need, 

while considering ‘Ae needs of our other imporcam customers, 

prima.rrcare psoviders. 

During the early decision alternative (EDA) phase of the 

placement cycle, provides have approximately nine 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 priority site, as ~ by law. 

Ovex B5 percent of providers are hired by individual conumanity


organizations. The communities receive notification that they


have been placed on the vacancy list 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 vacancies as scholars. As the hiring 

authority, they are recruiting scholL-s as well as others who 

may wish to senre in their communities. As a result, some sites will fill theL’ vacancieswith providers other than NESC 

schola~s. For this reason, scholars are encouraged to pursue 

theti options as soon as they get the HPOL. NESC’s gOal is to 

help fill all of the vacancies in the neediest c~ties, 

while matching all obligated scholars. 

The program has continuedto expand the n~ez of sites that axe available through loan repayment, enhanctig eff orta to 

target communities of greatest need. For the last three 

years, there have been approtitely t&ee vacancies available 

for each NKSC loan repayment contract. LOan repayment 

applicants are not obligateduntil they match to a site end 

have a loan repayment contractapproved by 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 program is an important retention 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 recruiting tool 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, provided tie incenzive that 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 consideration in 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 report’s characterizationof the scholarship and loan


repayment programs as being resperdvely more competitive and


less r%gorous does both programs a 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 embarking on 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 obligation several years prior to completing his/her 

education and beginning se~ice. In the case of loan 

repeyers, they are not obligated until they match to a site


and sign an agr~nt with DS”4.


The NESC has noted a progressive in~ase in retention rates over the last few years. Of the universe of scholars and loan 

repeyers who have completed their 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 scholars and 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 teaching primary care h an academic set-~g. 

The way in which providers are 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 providers and commnity orgmzations to facilitate 

retention, and will delete sites from tie vacancy lists which 

routinely do not manage theix practices appropriately. 

The statute mandates � fuU-time clinical practice.“ The intent was based on the belief that underse~ communities ~ 

full-time providers to improve the health of the c~ v“ 

Any change to the r~ent would necessitate a change in 

legislation. Full-time practice is defined as a minimum of 

45 weeks a year in practice. Obligated providers are permitted up to 7 weeks a year off-site for vacazion, sick 

leave, andtor continuing professional education. The NIiSC has 

provided more than S1 million annually for continuing 

professional education fox the last several years. Deferments 

are provided for residency ~-aining, and all NESC providezs 

are now required by statuze to be fully qualified in theiz 

professional specialty before they stazx sezzice. 

B-6 

—— 
The 

6 

_in9 1993 the NESC matched 193 schol~s and placed 477 loan 

repq yers. In addition, 406 scholeships were a~ed. 

NHsc ea~C”4 its site develo~mt conmam and other ongohg The . . 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.% generally work in areas which cannot carrently


suppoxz an econ~cally viable practice.


miss+on to locate prx~ care pmidm fi It mas is the where NRSC’S
 oth~ 

prozuciershave chosen not to go, and where healti care s-ices would not otherwise be availble. 

as a surprise to provide= to fiad that the c It should not come


wMch they are se=ing are frequently economictily OImunities and in

educationally disadvantigti. However, the NXSC believes that it can continue to at~-ae. pr~ CaXS pmide~ who want 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 frequently face lic~, 

acceptance, and site pratice ~m. The ~=~~g


*th professional orgmzatiom, States and State licensing


btmrds, and =~ties to remove these Prtwttce barriers and
 allow for the ftil utilization of these healti Providem as


members of intetisc~pltiq practice teams.


working with PIE Regional Offices and primary careNESC is also


associations to ensw that all pmidm are placed


situations where they can prac-ticethe full scope of in


professions. their


OIG Reconunendati
 on


3.	 The PHs should develop more ac~ate, complete, 

to-date vaca.xq lists. and upPHS COnunent


We Concur. The NHSC has improvti and till contiue to ~~ the vacanq list developenz and u+atig process. 

NXSC recruiters in the field are ustig laptop cqtersCurrently, to


access information in a c


~ty profile progrmn.


The NHSC continues to enhance the 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 looking at developing an on-line,


continuously updated file of available, eligible facilities.


The basis for these improvemmt~ ia to assure that all


Cusxomezs of NRSC’S 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 successful the 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 conference with 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 institutions upon receipt and ve=ificatioa of 

invoices. The PES Division of Commissioned Personnel 

processes the monthly stipends for students. A test program 

to implement direct deposit of stipend checks is mzrently 

under development. It is expected that tMs system will be 

fully implemented in the first half of 1994. 

Concerning loan repayments, DSLR prepares computerized payment


work sheets that account for what is due to each participant


at the point of contract between the -C and the participant.


These work sheets include information on 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 program’s experiencethat most complaints from 

providers about not receiving payments can be ‘~aced to the 

providers’ failure to repmx their correct address to the 

program. In nearly all cases of payment complaints reviewed 

by the program staff, the check v&- not delivered because of an incorretn or old address and 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 complete picture, we suggest that th$s 

mmPh mention tie sho=ge of primary care providers. 

2aae 2. fir st naraaranh 

This paragraph does not fully recognize the 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 State Activities is not a formalized 

organizational unit in HRSA’S 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 individual is 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 negotiaze with the site facilities over 

possible assignment. If an obligated scholar 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 concerted efforts to ensure that providers and 

factiities get started on the right foot. The first year at 

the site is the most critical in 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 confuse the older pm~m md cohorts studied 

by “he OIG, from che current effoms of the revitalized NHS&. 

Increasing contac: with field provide.% is one of the 

cornerstones of the “new” NIISC. 

B-9

. . . 

P-= 8, second Daraar?@ 

We agree that NESC expansion will require -== Communication and coordinationamong PES components and have 

taken some s@nifLcant steps to ~rove commuxdcation and 

coo~tion. Through work planaing processes, the NESC is 

CIUIY defining responsibilitiesas NESC expansion efforts 

are nnde-en. Pmgrsm officials are 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 repagment VaCaacy list. our


cozments on the OIG report’s ~dations discuss act$ons


taken or planned m provide zIore ac~ze and timely


information to both prmidara and facilities.


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