CHAPEL HILL - To their surprise, researchers at the University of North Carolina at Chapel Hill and colleagues have identified scores of programs around the United States that provide scholarships, loan forgiveness plans and incentives to doctors and others to practice in medically under-served areas. "Federal programs, such as the National Health Service Corps and the smaller Indian Health Service, are well-known efforts to provide doctors and other health practitioners to parts of the country, mostly rural areas, that don't have enough health workers," said Dr. Donald E. Pathman, senior fellow at the Cecil G. Sheps Center for Health Services Research. "By surveying every state to see what it provides, we've found what amounts to an unheralded health-care safety net spread by individual states to boost the number of primary-care practitioners in places with the greatest need. What's interesting is that nobody before knew the extent and apparent effectiveness of state efforts since there's no central clearinghouse for such information, not even the federal government."
Forty-one states sponsored such programs. In North Carolina, for example, six programs channel doctors, nurse practitioners, physicians' assistants and nurse midwives to under-served counties in exchange for financial incentives.
A report on the research appears in the Oct. 25 issue of the Journal of the American Medical Association. Besides Pathman, authors are Dr. Thomas R. Konrad, Dr. Tyndall Harris and Kathleen D. Crook of the Sheps center, Dr. Donald H. Taylor Jr. of Duke University's Terry Sanford Institute of Public Policy Studies and Dr. Tonya S. King of Pennsylvania State University.
Others are Tim M. Henderson of the National Conference of State Legislatures in Washington, D.C., James Bernstein and Thomas Tucker of the N.C. Office of Rural Health and Resource Development, Dr. Cora Spaulding of Piedmont Health Services in Carrboro and Dr. Gary G. Koch of the biostatistics department at the UNC-CH School of Public Health.
"More than 1,300 U.S. primary-care physicians and almost 400 nurse practitioners, physicians' assistants and nurse midwives are now serving out their obligations in needy areas because of these state programs," said Pathman, also associate professor of family medicine at the UNC-CH School of Medicine. "Those numbers are very similar to those of the National Health Service Corps, which had 1,000 physicians and just over 500 other health professionals."
Researchers found 82 state programs operating in the study year, 1996, including 29 loan repayment programs, 29 that offer scholarships in exchange for service, 11 providing loans, eight offering other direct financial incentives and five that support residents. The number of such programs doubled between 1990 and 1996.
Common features of state efforts were the mission to influence distribution of health-care workers within state borders, emphasis on primary-care workers and reliance on annual state appropriations and other public funding, the physician said.
"In 1996, after a decade of remarkable growth, states fielded an obligated primary care workforce comparable in size to the better known federal programs," he said. "These previously unheralded state programs, almost invisible nationally, are now a major portion of the U.S. health-care safety net and should be monitored, coordinated and evaluated. State programs no longer should be omitted from listings of safety net initiatives nor overlooked in future plans to further improve health-care access."
Note: Pathman can be reached at (919) 966-4270 or e-mail, don_pathman@unc.edu.
Contact: David Williamson, (919) 962-8596 or David_Williamson@unc.edu.
Journal
JAMA