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Research ArticleOriginal Research

Outcomes of States’ Loan Repayment and Forgiveness Programs From the Perspective of Safety Net Practice Administrators

Donald E. Pathman, Robert G. Sewell, Thomas Rauner, Marc Overbeck, Jackie Fannell and John Resendes
The Journal of the American Board of Family Medicine September 2022, jabfm.2022.AP.220092; DOI: https://doi.org/10.3122/jabfm.2022.AP.220092
Donald E. Pathman
University of North Carolina at Chapel Hill, Cecil G. Sheps Center for Health Services Research and Department of Family Medicine (DEP); Alaska Department of Health and Social Services, Office of Healthcare Access, Section on Rural and Community Health Systems, Division of Public Health (RGS); Nebraska Department of Health and Human Services, Primary Care Office and Office of Rural Health, Division of Public Health (TR); Oregon Health Authority. Oregon Primary Care Office (MO); National Rural Recruitment and Retention Network (3RNET) (JF); Office of Rural Health, North Carolina Department of Health and Human Services (JR).
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Robert G. Sewell
University of North Carolina at Chapel Hill, Cecil G. Sheps Center for Health Services Research and Department of Family Medicine (DEP); Alaska Department of Health and Social Services, Office of Healthcare Access, Section on Rural and Community Health Systems, Division of Public Health (RGS); Nebraska Department of Health and Human Services, Primary Care Office and Office of Rural Health, Division of Public Health (TR); Oregon Health Authority. Oregon Primary Care Office (MO); National Rural Recruitment and Retention Network (3RNET) (JF); Office of Rural Health, North Carolina Department of Health and Human Services (JR).
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Thomas Rauner
University of North Carolina at Chapel Hill, Cecil G. Sheps Center for Health Services Research and Department of Family Medicine (DEP); Alaska Department of Health and Social Services, Office of Healthcare Access, Section on Rural and Community Health Systems, Division of Public Health (RGS); Nebraska Department of Health and Human Services, Primary Care Office and Office of Rural Health, Division of Public Health (TR); Oregon Health Authority. Oregon Primary Care Office (MO); National Rural Recruitment and Retention Network (3RNET) (JF); Office of Rural Health, North Carolina Department of Health and Human Services (JR).
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Marc Overbeck
University of North Carolina at Chapel Hill, Cecil G. Sheps Center for Health Services Research and Department of Family Medicine (DEP); Alaska Department of Health and Social Services, Office of Healthcare Access, Section on Rural and Community Health Systems, Division of Public Health (RGS); Nebraska Department of Health and Human Services, Primary Care Office and Office of Rural Health, Division of Public Health (TR); Oregon Health Authority. Oregon Primary Care Office (MO); National Rural Recruitment and Retention Network (3RNET) (JF); Office of Rural Health, North Carolina Department of Health and Human Services (JR).
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Jackie Fannell
University of North Carolina at Chapel Hill, Cecil G. Sheps Center for Health Services Research and Department of Family Medicine (DEP); Alaska Department of Health and Social Services, Office of Healthcare Access, Section on Rural and Community Health Systems, Division of Public Health (RGS); Nebraska Department of Health and Human Services, Primary Care Office and Office of Rural Health, Division of Public Health (TR); Oregon Health Authority. Oregon Primary Care Office (MO); National Rural Recruitment and Retention Network (3RNET) (JF); Office of Rural Health, North Carolina Department of Health and Human Services (JR).
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John Resendes
University of North Carolina at Chapel Hill, Cecil G. Sheps Center for Health Services Research and Department of Family Medicine (DEP); Alaska Department of Health and Social Services, Office of Healthcare Access, Section on Rural and Community Health Systems, Division of Public Health (RGS); Nebraska Department of Health and Human Services, Primary Care Office and Office of Rural Health, Division of Public Health (TR); Oregon Health Authority. Oregon Primary Care Office (MO); National Rural Recruitment and Retention Network (3RNET) (JF); Office of Rural Health, North Carolina Department of Health and Human Services (JR).
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Article Figures & Data

Tables

    • View popup
    Table 1.

    List of State Service Programs by Type of Program With Number of Completed Administrator Questionnaires in Analyses

    StateProgram NameLoan Repayment ProgramsState Forgivable Loan Programs
    Solely-State LRPState-NHSC LRP
    AlaskaAlaska SHARP-I Program39
    Alaska SHARP-II Program38
    DelawareDelaware State LRP10
    IowaPrimary Care Recruitment and Retention Endeavor LRP (PRIMECARRE)13
    MissouriMissouri State LRP60
    Primary Care Resource Initiative for Missouri Program (PRIMO)38
    MontanaMontana State LRP2
    NebraskaNHSC Nebraska State LRP23
    Nebraska LRP67
    Nebraska Student Loan Program10
    NevadaNevada Health Service Corps LRP24
    New YorkNew York Primary Care Service Corps6
    North CarolinaNorth Carolina State LRP14
    Community Practitioner Program55
    North Carolina LRP121
    North DakotaNorth Dakota Federal / State LRP19
    North Dakota Dentist LRP14
    North Dakota LRP43
    OregonOregon Behavioral Health LRP13
    Oregon Partnership State LRP15
    Oregon Health Care Provider LRP8
    Oregon Medicaid Primary Care LRP48
    Oregon Primary Care Loan Forgiveness12
    Rhode IslandRhode Island Health Professionals LRP37
    VirginiaVirginia State LRP22
    WyomingWyoming State LRP3
    Total41328160
    • Abbreviations: LRP, Loan Repayment Program; NHSC, National Health Service Corps.

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    Table 2.

    Disciplines, Service Sites and Special Population Groups, by State Service Program

    Total
    (n = 754)
    Solely-State LRP
    (n = 413)
    State-NHSC LRP
    (n = 281)
    State Forgivable Loan Programs
    (n = 60)
    P Value for group differences
    Program clinician disciplines, n (weighted %)
     Physician208 (27%)118 (28%)60 (22%)30 (48%)<0.001
     Advanced Practice Nurse140 (18%)83 (20%)52 (17%)5 (7%)
     Physician Assistant97 (13%)62 (15%)30 (11%)5 (9%)
     Dentist133 (17%)70 (17%)51 (17%)12 (20%)
     Behavioral health disciplines*88 (13%)37 (9%)46 (19%)5 (9%)
     Other disciplines88 (13%)43 (12%)42 (15%)3 (6%)
    Types of site, n (weighted %)
     FQHC, other health centers228 (29%)96 (24%)115 (38%)17 (28%)<0.001
     Rural Health Clinic93 (12%)48 (11%)34 (13%)11 (19%)
     Mental health and substance use  disorder facility77 (11%)47 (11%)27 (11%)3 (6%)
     Health department30 (4%)30 (7%)0 (0%)0 ( 0%)
     Pediatric clinic—office or  hospital-based38 (5%)30 (7%)7 (2%)1 (2%)
     IHS and tribal site27 (5%)16 (5%)11 (7%)0 (0%)
     Prison/correctional facility9 (2%)2 (1%)7 (4%)0 (0%)
     Other office-based practice169 (21%)112 (26%)38 (13%)19 (32%)
     Hospital-based practice83 (11%)32 (8%)42 (13%)9 (15%)
    Special patient groups at sites, mean weighted % †
     Medicaid, IHS insurance, tribal  insurance and uninsured52.8%55.4%50.0%47.4%<0.001
     Black, Hispanic and Native,  American/Alaskan Native32.5%35.5%31.2%15.4%<0.001
    • Abbreviations: LRP, Loan Repayment Program; NHSC, National Health Service Corps; FQHC, Federally Qualified Health Center; CHC, Community Health Center; IHS, Indian Health Service.

    • ↵* Includes Licensed Clinical Social Workers (n = 31), Licensed Professional Counselors (28), Psychologists (17), Licensed Mental Health Practitioners (6), Marriage and Family Therapists (3) and Psychiatric Nurse Practitioners (2).

    • ↵† Percentages among responses with non-missing data. Missing data range from 3.5% to 6.0% across special population groups.

    • View popup
    Table 3.

    Weighted Percentages* of Administrators’ Perceptions of the Impact of the State Service Program on Their Site’s Ability to Recruit and Retain Clinicians of the Participating Clinician’s Discipline, by the Three Program Types

    Perceived EffectsTotalSolely-State LRPsState-NHSC LRPsForgivable Loan ProgramsP Value for Group Differences
    (n = 735)(n = 396)(n = 279)(n = 60)
    Recruitment
    In general, how easy or difficult is it for this clinic to recruit this discipline?% difficult66.1%63.8%71.8%52.8%0.019
    % easy14.5%16.4%11.1%18.9%0.137
    How much easier or more difficult was it to recruit this clinician because of the state service program?% easier81.7%82.2%82.3%75.0%0.53
    % more difficult3.1%3.2%3.2%2.3%0.89
    How much quicker or longer did it take to fill this position because of the state service program% quicker65.4%67.3%64.3%58.3%0.53
    % longer1.1%1.5%0.8%0.0%0.31
    How much less or more expensive was it to fill this position because of the state service program?% less expensive34.8%34.9%35.6%29.8%0.80
    % more expensive9.6%6.3%15.8%0.0%0.002
    Retention
    Do you anticipate that this specific clinician’s participation in the state service program will help her/him remain longer at this practice?% longer78.8%78.2%82.6%62.3%0.008
    % shorter3.0%2.3%3.5%5.7%0.47
    In general, do you anticipate that clinicians of this discipline remain longer or shorter in your practice if they participate in this state service program?% longer83.0%83.2%85.5%67.9%0.015
    % shorter1.8%1.5%2.4%0.0%0.41
    • Abbreviations: NHSC, National Health Service Corps; LRP, Loan Repayment Program.

    • ↵* Results from Likert-scaled questionnaire items with 5 response options and a neutral middle value. Weighted percentage figures (e.g., “% easier”) represent the combined weighted percent of subjects reporting the two values at the relevant end of the scale (e.g., weighted % “much easier” combined with weighted % “somewhat easier”).

    • View popup
    Table 4.

    Weighted Percentages of Administrators’ Perceptions of the Job Performance of Participating Clinicians and the Site’s Involvement with Service Programs, by the Three Service Program Types

    RatingsTotalSolely-State LRPsState-NHSC LRPsForgivable Loan ProgramsP Value for Group Differences
    (n = 735)(n = 396)(n = 279)(n = 60)
    Clinician
    Provides good quality care% well or very well *96.9%96.7%96.8%98.1%0.82
    Is a positive contributor within the practice% well or very well92.4%91.9%92.6%94.3%0.69
    Overall performance on the job% well or very well93.8%93.5%94.0%94.3%0.88
    Site Involvement/Interaction With Service Program
    While looking to hire or qualify clinicians for the program% very good or excellent †67.4%65.2%71.6%60.4%0.21
    % fair or poor ‡7.6%7.1%6.7%15.1%0.14
    As clinicians participate in the program% very good or excellent70.3%69.7%73.5%58.350.19
    % fair or poor5.2%5.3%3.5%13.2%0.036
    Overall participation with the program% very good or excellent69.3%67.7%72.9%62.3%0.29
    % fair or poor6.0%6.9%3.5%13.2%0.09
    • Abbreviations: NHSC, National Health Service Corps; LRP, Loan Repayment Program.

    • ↵* Versus “neither well nor poorly,” “poorly,” and “very poorly”.

    • ↵† Versus” good,” “fair,” and “poor”.

    • ↵‡ Versus “good,” “very good,” and “excellent”.

    • View popup
    Table 5.

    Adjusting Outcome Differences† Found across the Three Types of State Service Programs in Bivariate Analyses for Differences in Their Participants’ Disciplines, Types of Practice Sites, and Patient Race-Ethnicity

    It is generally difficult for this practice to recruit clinicians of this disciplineIt was more expensive to fill a position because of this service programParticipation in this service program will help this clinician remain longerParticipation in this service program generally yields longer retention for clinicians of this discipline
    VariableOdds RatioOdds RatioOdds RatioOdds Ratio
    State-NHSC LRP
    (vs Solely-State LRP)
    1.64 *3.25 ***1.191.21
    Forgivable Loan Program
    (vs Solely-State LRP)
    0.590.000.52 *0.44 *
    Physician discipline1.55 *0.530.850.99
    Behavioral health discipline0.980.891.340.97
    FQHC or CHC0.620.38 **0.950.77
    “Other” office-based practice0.50 **0.680.530.58
    Combined % Black, Hispanic and Native American patients0.991.001.014 **1.01
    Model P value<0.001<0.001<0.0010.02
    Model Nagelkerke R20.0620.1120.0790.046
    • Abbreviations: LRP, Loan Repayment Program; NHSC, National Health Service Corps; FQHC, Federally Qualified Health Center; CHC, Community Health Center.

    • ↵† Logistic regression models within the SPSS complex samples procedure.

    • ↵* P ≤ .05.

    • ↵** P ≤ .01.

    • ↵*** P ≤ .001.

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Outcomes of States’ Loan Repayment and Forgiveness Programs From the Perspective of Safety Net Practice Administrators
Donald E. Pathman, Robert G. Sewell, Thomas Rauner, Marc Overbeck, Jackie Fannell, John Resendes
The Journal of the American Board of Family Medicine Sep 2022, jabfm.2022.AP.220092; DOI: 10.3122/jabfm.2022.AP.220092

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Outcomes of States’ Loan Repayment and Forgiveness Programs From the Perspective of Safety Net Practice Administrators
Donald E. Pathman, Robert G. Sewell, Thomas Rauner, Marc Overbeck, Jackie Fannell, John Resendes
The Journal of the American Board of Family Medicine Sep 2022, jabfm.2022.AP.220092; DOI: 10.3122/jabfm.2022.AP.220092
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