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Providers look to help from workforce program
By Adam Sonfield
Senior Public Policy Associate
For four decades, safety-net providers such as community health centers have turned to the National Health Service Corps (NHSC) for help with maintaining a well-trained and credentialed workforce. Specialized family planning centers have had little access to NHSC-supported clinicians, but additional funding for the program might provide an opportunity to change that, according to Rachel Benson Gold, MPA, director of policy analysis at the Guttmacher Institute.1
All safety-net providers are hindered in recruiting and retaining clinicians because their limited budgets put them at a disadvantage in competing with hospitals and private-sector providers. The recession and government budget woes have added to these problems, as has a national shortage of primary care providers. Beyond these general problems, family planning centers must maintain a workforce (primarily, nurse practitioners, physician assistants, and nurse midwives) with training specific to the delivery of family planning services. They also must deal with additional local problems, such as low demand and long commutes in rural areas and clientele who speak a wide variety of languages in urban areas. One important program to help address these workforce issues, a training program funded for three decades by the Title X family planning program, has been phased out, largely because of a movement toward increased credentialing standards for nurse practitioners.
Congress created the NHSC in 1970 to address these workforce challenges for safety-net providers in areas designated by the federal government as Health Professional Shortage Areas (HPSAs). It does so through two programs: one providing upfront scholarships, and a second one providing loan repayments, both in exchange for two or more years of service at sites in these HPSAs. The programs support more than 8,000 clinicians, including physicians, physician assistants, nurse practitioners, and certified nurse midwives.2
Requirements for sites
For an NHSC-supported clinician to be placed at a specific service site, that site must receive approval from the program. Sites must meet such requirements as being located in a HPSA; participating in Medicaid and the Children's Health Insurance Program; accepting all patients, regardless of ability to pay, on a discounted sliding-fee scale; and demonstrating workforce needs and difficulties in recruitment. The program traditionally has had limited funds and has set second-tier conditions for a site to receive priority. Notably, priority sites must provide primary care broadly defined by the program to include services related to family medicine, internal medicine, or obstetrics and gynecology, among other areas and must be part of "a system of care that provides a continuum of services, including comprehensive primary health care and appropriate referrals or arrangements for secondary and tertiary care."3
Community health centers, many of which receive funding through the Title X program, traditionally have received large numbers of NHSC placements. Specialized family planning centers have had far more difficulty receiving approval as an NHSC site. Yet, most of those located in an HPSA should be able to meet the core requirements for participation, and in fact, the Title X program includes many similar requirements, such as a sliding fee scale. Most of the criteria for priority status also can be readily met. The continuum-of-services condition is likely the most problematic, as many family planning centers are not formally part of a comprehensive primary care agency. However, Title X requires programs to refer clients for care outside their expertise, something that family planning centers facilitate through referral arrangements with other providers in the community. Indeed, family planning centers often serve as an entry point to the healthcare system, with six in 10 of their clients viewing the center as their usual source of medical care.4
Going forward, there might be more opportunities for new sites, including specialized family planning centers, to receive NHSC placements, even if they do not entirely meet all of the program's conditions for priority status. The program has received two major boosts in federal funding: a $300 million expansion under the stimulus legislation enacted early in 2009, and another $1.5 billion over five years under the 2010 healthcare reform legislation.5,6 To improve their chances for approval as NHSC placement sites, and to otherwise adapt to health reform and other changes in the U.S. health care system, family planning centers might wish to reevaluate and bolster their relationships with other local providers.