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

BACKGROUND: Nearly every state offers loan repayment (LRP) and some offer loan forgiveness to clinicians who commit to work in safety net practices. The effectiveness of these programs from the perspective of safety net practices is largely unknown. OBJECTIVES: To assess safety net practice administrators' assessments of key outcomes for the 3 principal types of state service programs: LRPs funded by states, LRPs funded jointly by states and National Health Service Corps, and loan forgiveness programs. SUBJECTS: Administrators of safety net sites where primary care, behavioral health and dental health clinicians began serving in 26 state service programs in 14 states from 2011 to 2018. Survey responses were received from 455 administrators reporting on 754 of 1380 clinicians (54.6%). OUTCOME MEASURES: Administrators' ratings of their sites' difficulty recruiting clinicians; relative ease, quickness and cost of recruiting the participating (index) clinician with the service program; program expected effects on participants' retention; participants' job performance. RESULTS: Most administrators (66.1%) reported that recruiting clinicians of the index clinician's discipline is generally difficult but made easier (81.7%) and quicker (65.4%) with the service program, but only sometimes less expensive (34.8%). 78.8% of administrators anticipate that the clinicians will remain longer because of program participation. Participants are perceived to practice good quality care (96.9%) and be positive contributors (92.4%). Administrators' assessments are generally similar for the 3 types of programs. CONCLUSIONS: Administrators of safety net practices generally perceive states' loan repayment and loan forgiveness programs succeed in helping them recruit and retain good clinicians.

Moral distress among clinicians working in US safety net practices during the COVID-19 pandemic: a mixed methods study.

OBJECTIVE: To explore the causes and levels of moral distress experienced by clinicians caring for the low-income patients of safety net practices in the USA during the COVID-19 pandemic. DESIGN: Cross-sectional survey in late 2020, employing quantitative and qualitative analyses. SETTING: Safety net practices in 20 US states. PARTICIPANTS: 2073 survey respondents (45.8% response rate) in primary care, dental and behavioural health disciplines working in safety net practices and participating in state and national education loan repayment programmes. MEASURES: Ordinally scaled degree of moral distress experienced during the pandemic, and open-ended response descriptions of issues that caused most moral distress. RESULTS: Weighted to reflect all surveyed clinicians, 28.4% reported no moral distress related to work during the pandemic, 44.8% reported 'mild' or 'uncomfortable' levels and 26.8% characterised their moral distress as 'distressing', 'intense' or 'worst possible'. The most frequently described types of morally distressing issues encountered were patients not being able to receive the best or needed care, and patients and staff risking infection in the office. Abuse of clinic staff, suffering of patients, suffering of staff and inequities for patients were also morally distressing, as were politics, inequities and injustices within the community. Clinicians who reported instances of inequities for patients and communities and the abuse of staff were more likely to report higher levels of moral distress. CONCLUSIONS: During the pandemic's first 9 months, moral distress was common among these clinicians working in US safety net practices. But for only one-quarter was this significantly distressing. As reported for hospital-based clinicians during the pandemic, this study's clinicians in safety net practices were often morally distressed by being unable to provide optimal care to patients. New to the literature is clinicians' moral distress from witnessing inequities and other injustices for their patients and communities.

Satisfaction of the Primary Care, Mental Health, and Dental Health Clinicians of the National Health Service Corps Loan Repayment Program.

The National Health Service Corps (NHSC) aims to foster a positive service experience for its clinicians to promote long-term retention. We assess the satisfaction of primary care, dental, and mental health clinicians in the NHSC's Loan Repayment Program (LRP). Survey data are from 1,193 clinicians (72.4% response) who completed NHSC LRP contracts in 16 states from July 2015 through December 2016. Eighty-one percent reported overall satisfaction with their work and practice, without differences across disciplines. Nearly 95% were satisfied with the mission and patients of their practices. Fewer clinicians were satisfied with compensation (51%) and time demands of work (36%). Ninety-four percent reported the NHSC experience met or exceeded their expectations, and 94% recommend the NHSC LRP to others. In summary, the NHSC LRP experience is generally positive for clinicians of all disciplines. Clinicians' issues with their incomes and with the time demands of their work deserve attention from the NHSC.

A Comparison of the J-1 Visa Waiver and Loan Repayment Programs in the Recruitment and Retention of Physicians in Rural Nebraska.

PURPOSE: There is a dearth of literature evaluating the effectiveness of programs aimed at recruiting and retaining physicians in rural Nebraska. Taking advantage of the Nebraska Health Professional Tracking System, this study attempts to comparatively assess the effectiveness of the J-1 visa waiver and state loan repayment programs in the recruitment and retention of physicians in rural Nebraska. METHODS: A mixed methods approach was used. We tracked 240 physicians who enrolled in the J-1 visa waiver and state loan repayment programs between 1996 and 2012 until 2013. In addition, key informant interviews were conducted to obtain perspectives on the recruitment and retention of physicians in rural Nebraska through the 2 programs. FINDINGS: Results from multilevel survival regression analysis indicated that physicians enrolled in the J-1 visa waiver program were more likely to leave rural Nebraska when compared with those enrolled in the state loan repayment program. Participants in the qualitative study, however, cautioned against declaring one program as superior over the other, given that the 2 programs addressed different needs for different communities. In addition, results suggested that fostering the integration of physicians and their families into rural communities might be a way of enhancing retention, regardless of program. CONCLUSION: The findings from this study highlight the complexity of recruitment and retention issues in rural Nebraska and suggest the need for more holistic and family-centered approaches to addressing these issues.