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Financial Returns to Society by National Health Service Corps Scholars Who Receive Training as Physician Assistants and ...

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PAGE 1

FINANCIAL RETURNS TO SOCIETY BY NATIONAL HEALTH SERVICE CORPS SCHOLARS WHO RECEIVE TRAINING AS PHYSICIAN ASSISTANTS AND NURSE PRACTITIONERS By ROBERT J. PHILPOT JR. A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2005

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Copyright 2005 by Robert J. Philpot Jr.

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This document is dedicated to the clinicians of the National Health Service Corps. Your unwavering dedication to the medically unders erved certainly makes you Americas Health Care Heroes.

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iv ACKNOWLEDGMENTS Thanks to the patience and generosity of colleagues, committee members, friends and family, working on this dissertation has b een a rich and rewarding experience. I am grateful to those who lent cr itical support, patiently listened while I discussed the current state of my research, and simply gave me space and time to work. Dr. David Honeyman, the chair of my comm ittee, was extremely helpful in all of my graduate studies. I am grateful for his willingness to discuss va rious aspects of my project even by cell phone while vacationing in another state. His demeanor and sage advice put things into reasonable perspective when everything felt chaotic. Dr. Parker Small took the time to help me focus on the dissertation from the very beginning. Always eager to hear about my pr ogress, it was not unusual for him to call from Cape Cod to discuss my findings. I am gr ateful that he, too, wa s willing to give up some of his vacation time to critique my work. Dr. Larry Tyree always seemed to have time to listen to my concerns and aspirations. From family and work responsibil ities to my involvement in Operation Iraqi Freedom, he was always availabl e for advice and encouragement. Dr. Dale Campbell was an early influence during my graduate studies. He opened my eyes to the diverse and exciting world of the community college and to the world of educational leadership and administration. Hi s careful analysis and critique of my performance helped me to better understand wh at it takes to excel in higher education.

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v My colleagues and friends at the University of Florida Physician Assistant Program were all directly or indir ectly responsible for my success. Wayne Bottom, Dean and Director of the Program, patiently gave me opportunities and time to develop as a faculty member and doctoral student. Joan Crisman was willing to proofread my manuscript and provide excellent feedback. The rest of the f aculty and staff were always willing to listen and provide feedback as I repe atedly discussed my research. For all of this I am, indeed, grateful. I thank the soldiers from Camp Blanding who volunteered in their off-duty time to help me address, stamp and stuff envelopes. Similarly I am grateful to the graduate students who volunteered to file and tally the survey results as they came in. This was important but tedious work that has not gone unnoticed. Last, but certainly not least, I am gr ateful to my family. Their support and encouragement were instrumental in getti ng me through some of the more challenging phases of this research. Cynthia is my f oundation. She never complained when I needed time and space to work. Despite the enormous challenges she faced in her battle with cancer she continually sacrificed her own time to cove r my responsibilities at home. Finally, I appreciate my two sons, Rob and Au stin, for enduring my absence during all of my graduate studies and for sharing the wonders and challenges of adolescence.

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vi TABLE OF CONTENTS page ACKNOWLEDGMENTS.................................................................................................iv LIST OF TABLES.............................................................................................................ix LIST OF FIGURES.............................................................................................................x ABSTRACT....................................................................................................................... xi CHAPTER 1 INTRODUCTION........................................................................................................1 Definition of Terms......................................................................................................3 Statement of the Problem..............................................................................................4 Conceptual Framework.................................................................................................6 Financing Physician Assistant a nd Nurse Practitioner Training..................................9 Measuring Production.................................................................................................12 Fiscal Returns to the Individual...........................................................................12 Fiscal Returns to Society.....................................................................................14 Justification for the Study...........................................................................................15 Limitations..................................................................................................................19 2 REVIEW OF THE LITERATURE............................................................................21 The Maldistribution of Health Care Providers in the United States...........................21 The Use of Non-Physician Clinicians.........................................................................28 Nurse Practitioners......................................................................................................29 Profile..................................................................................................................30 Training...............................................................................................................30 Scope of Practice.................................................................................................31 Salaries................................................................................................................32 Work Settings......................................................................................................32 Productivity.........................................................................................................32 Physician Assistants....................................................................................................33 Profile..................................................................................................................34 Physician Assistant Training...............................................................................34 Salaries................................................................................................................35 Scope of Practice.................................................................................................36

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vii Work Settings......................................................................................................36 Productivity.........................................................................................................37 Assistance to Health Profession Shortage Areas........................................................38 Medicare..............................................................................................................38 Medicaid..............................................................................................................38 Foundations and Trusts........................................................................................39 Public Health Service Act...................................................................................40 Area Health Education Centers...........................................................................41 National Health Service Corps............................................................................42 Economic Incentives for Community Health Centers.........................................43 Federal Support for Higher Education........................................................................44 Recent Federal Involvement in Higher Education..............................................47 Federal Support for Medical Education..............................................................49 Federal Funding of PA and NP Training.....................................................50 The National Health Service Corps Scholarship Program...........................51 Accountability and Workforce Contingent Financial Aid Programs..................60 Human Capital Theory...............................................................................................63 The Benefits of Education...................................................................................68 Fiscal Returns......................................................................................................70 Individual and So cietal Costs..............................................................................72 Return Methodologies................................................................................................72 Earnings Differential...........................................................................................72 Net Present Value Approach...............................................................................73 Internal Rate of Return........................................................................................74 Investment Returns.....................................................................................................75 Positive Production..............................................................................................75 Negative Production............................................................................................75 3 METHODOLOGY.....................................................................................................77 Research Design.........................................................................................................77 Participants..........................................................................................................78 Participant Characteristics...................................................................................79 Payback................................................................................................................79 Present Value.......................................................................................................80 Social Debt Ratio.................................................................................................80 Qualifying Scholars for the Study.......................................................................81 Data Collection Procedures.................................................................................81 Treatment of the Data..........................................................................................81 Payback.......................................................................................................................8 3 Societal Payback..................................................................................................83 Individual Payback..............................................................................................83 Assumptions........................................................................................................84 Comparisons........................................................................................................84 Effect Size...........................................................................................................86

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viii 4 RESULTS...................................................................................................................87 Results of the Study....................................................................................................88 Returns to Society.......................................................................................................91 Research Question 1............................................................................................91 Research Question 2............................................................................................92 Research Question 3............................................................................................93 Research Question 4............................................................................................95 Research Question 5............................................................................................97 Summary.....................................................................................................................99 5 CONCLUSIONS AND RECOMMENDATIONS FOR RESEARCH....................102 Introduction...............................................................................................................102 Findings....................................................................................................................104 Research Question 1..........................................................................................104 Research Question 2..........................................................................................105 Research Question 3..........................................................................................106 Research Question 4..........................................................................................108 Research Question 5..........................................................................................109 Conclusion................................................................................................................110 Recommendations for Future Research....................................................................111 Summary...................................................................................................................113 APPENDIX A ABBREVIATIONS AND ACRONYMS.................................................................115 B SURVEY MAILED TO NURSE PRACTITIONERS.............................................117 C SURVEY MAILED TO PHYSICIAN ASSISTANTS............................................118 LIST OF REFERENCES.................................................................................................119 BIOGRAPHICAL SKETCH...........................................................................................128

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ix LIST OF TABLES Table page 4-1. Consumer Price Index and Cumulative Discount Rates.............................................89 4-2. Federal Tax Brackets..................................................................................................90 4-3. Years of Scholarship Support by Discipline...............................................................91 4-4 Minimum and Maximum Social De bt Ratio Factors by Profession............................93 4-5 Independent-Samples t-test Analysis of Factors Affecting Payback Potential...........94 4-6. Split-plot ANOVA of Training and Discipline on Salaries........................................98

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x LIST OF FIGURES Figure page 1-1. A Comparison of Sources Used by Physic ian Assistants and Nurse Practitioners to Pay for Training...................................................................................................10 4-1. Comparison of Cumula tive Taxes Generated.............................................................92 4-2. Scholarship Payback by Social Debt Ratio................................................................93 4-3. Scholarship Payback by Profession............................................................................94 4-4. Foregone Income by Nurse Practi tioners and Physic ian Assistants...........................97 4-5. Comparison of Pre-traini ng and Post-training Wages................................................98

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xi Abstract of Dissertation Presen ted to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy FINANCIAL RETURNS TO SOCIETY BY NATIONAL HEALTH SERVICE CORPS SCHOLARS WHO RECEIVE TRAINING AS PHYSICIAN ASSISTANTS AND NURSE PRACTITIONERS By Robert J. Philpot Jr. December 2005 Chairman: David Honeyman Major Department: Educational Leadership, Policy and Foundations The purpose of this study was to examine the investment return to society and to the individual for the National Health Servi ce Corps (NHSC) scholarship recipients from physician assistant (PA) and nur se practitioner (NP) programs in the United States who would have completed service obligations between the years 2003 and 2006. The study examined the difference in the amount of Fe deral taxes generated between the preand post-training wages compared to the cost of students schola rship awards and differences in payback potential between NPs and PAs. Di fferences in foregone earnings, scholarship debt and starting salaries are also compared. This study examined 187 NHSC scholars w ho would have completed their service obligation between the years 2003 and 2006 in numerous Health Professional Shortage Areas (HPSAs) across the nation. The initial da ta were collected by surveys sent to 314 scholarship recipients as well as existing censu s data from the Bureau of Labor Statistics,

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xii the American Academy of Physician Assist ants and the American Academy of Nurse Practitioners. The major findings of this study were that (a) scholars repaid societys investment within 19 years after graduati on, (b) PA scholars generated more tax revenue than NP scholars, (c) time to repayment was highly dependent upon scholarship debt, (d) nurse practitioner students were re quired to forego an averag e of $5,216.00 more potential income than physician assistant students dur ing training. While most scholars received more income as a result of training, the PA sc holars in this study appeared to enjoy larger increases in salary than NP scholars. Fina lly, the service period for NHSC scholars was, in no way, contingent on the amount of money invested in their scholarship.

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1 CHAPTER 1 INTRODUCTION The Federal government, through various programs, provides more primary care clinicians to Health Profe ssion Shortage Areas (HPSAs) in the United States than any other source (see Appendix A for a complete li st of abbreviations). During fiscal year 2003 the Department of Health and Huma n Services (DHHS) received 20 % ($25.4 billion) of the Federal on -budget funds for education. From these funds the DHHS provided $46 million to the National Health Se rvice Corps (NHSC) (U.S. Department of Education, 2004). These funds were used to support numerous programs with the aim of providing doctors, dentists, phys ician assistants, nurse prac titioners, and other trained health care professionals to care for the me dically underserved populations of America. In 1970 the Emergency Health Personnel Ac t, which authorized assignment of Federal personnel to shortage areas, served as a mandate for the cr eation of the National Health Service Corps. Two years later a gr oup of clinicians consisting of 14 physicians, four dentists and two nurses were assigned to underserved communities. Later that year Congress passed amendments to the Emergenc y Health Personnel Act that authorized scholarships to aspiring health professionals in return for service in communities with critical health needs. Throughout the rest of the decade and into the 1980s, the NHSC identified HPSAs, created loan repayment programs, and expanded scholarship offerings to a wider range of health care providers. W ith this expansion came large increases in funding (National Health Se rvice Corps [NHSC], 2004b).

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2 The NHSC scholarship program was mandate d by Congress to supply health care professionals trained in those disciplines and specialties most needed to deliver quality primary health care services to HPSAs with the greatest ne ed. Scholarship funds were made available to health professional student s training for a period of up to 4 years. In return, the clinicians served in an identif ied area of need 1 year for each year of scholarship support. The expectation of th e DHHS was that many of these clinicians would continue to serve in th ese underserved areas after their service obligation had been fulfilled. Repeated training and recruitment of clinicians for these HPSAs required additional funding. One of the missions of the DHHS was to st aff HPSAs with well trained clinicians. This was done through a number of Federal in itiatives to include the NHSC Scholarship program. There was an inherent expectation that the scholarship was a good investment. However, no research was found in the literatu re that provides an estimate of financial return from the governments scholarship inve stment. There was also an expectation that certain societal benefits accrue from the availa bility of primary health care services in an underserved community. Yet few, if any, studi es attempted to measure the societal dividends of the NHSC scholarship program. This study provides an evaluation of the NHSC Scholarship for PAs and NPs with the hope that more efficient ways of making health care services av ailable to Americas medically underserved populations could be developed. Careful analysis of the relationship between funds invested and outcomes achieved can lead to funding and policy decisions that result in a mo re efficient use of tax dollars.

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3 Definition of Terms The following definitions were used in this study: Federally Qualified Health Center (FQHC) is a type of provider defined by the Medicare and Medicaid statutes. FQHC s include all organizations receiving grants under section 330 of the Public Health Service Act. Health Professional Shortage Area (HPSA) is a geographi c area, population group, public or nonprofit private medical facility or other facility determined by the Secretary of Department of Health and Human Services to ha ve a shortage of primary health care professionals. Index of Medical Underservice (IMU) is a score used to measure the adequacy of medical service in a service area. The index involves four variables ratio of primary medical care physicians per 1,000 population, infant mortality rate, percentage of the population with in comes below the poverty level, and percentage of the population age 65 or over. The value of each of these variables for the service area is converted to a weighted value, according to established criteria. The four values are summ ed to obtain the area's IMU score. Medically Underserved Area (MUA) is a geographic ar ea or population designated by the Department of Health and Human Se rvices based on an index of variables known as the index of medical underservice (IMU). Non-physician clinician (NPC) is a licensed medical provider, usually a physician assistant, nurse practitioner or nurse midwife who practices within limited guidelines or under the supervision of a physician. Payback Potential refers to the potential to repa y debt through the generation of additional tax revenues. Persistence refers to a scholars continued serv ice in a designated health profession service area beyond the terms of the service obligation. Scholar refers to a recipient, past or present, of the NHSC Scholarship. Scholarship is an award usually based on academic achievement, community involvement, or similar factors. Most sc holarships do not require repayment. For the purposes of this study, the term schol arship specifically refers to the NHSC Scholarship. Service Obligation refers to a defined period of se rvice, normally 2 to 4 years in a medically underserved area to satisfy the terms of the NHSC Scholarship contract. Generally, each year of scholarship suppor t incurs 1 year of service obligation.

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4 Social Debt Ratio is the monetary value of scholarsh ip debt to be forgiven during a defined period divided by the income for the same period. Social Debt Ratio Factor was derived from the ratio of total scholarship costs to tax revenue generated during the obligated service period. Workforce Contingent Financial Aid (WCFA) programs provide financial aid to students by assisting individuals with thei r educational expenses in exchange for service in either specified fi elds or specified locations. Statement of the Problem The problems addressed in this research invo lved the fiscal return to society and to the individual from the Federal governmen ts investment in NHSC scholarships for physician assistants and nurse practitioners. The research was specific to PAs and NPs who received NHSC scholarships to complete training programs across the United States between 2001 and 2004. The study examined the following specific research questions: 1. Is the difference in the amount of Fede ral taxes generated between the preand post-training wages sufficient to e qual the cost of sc holarship awards? 2. How does the social debt ratio factor (t he ratio of total sc holarship costs to tax revenue generated during the obligat ed service period) change the time required to generate enough Federal ta xes sufficient to equal the cost of scholarship awards? 3. Are there differences in payback poten tial between nurse practitioners and physician assistants? 4. Are there differences in foregone ea rnings during training between nurse practitioners and phys ician assistants? 5. Do NHSC PA and NP scholars who comp lete training receive more or less income after graduation than before completion of their training program? Few, if any, studies have been publishe d that pertain to the NHSC Scholarship program for physician assistants and nurse pr actitioners or to th e benefits derived by society and by the individual students.

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5 A 1995 U.S. General Accounting Office (GAO) report analyzed cost, retention, and other data in an effort to (1) compare co sts and benefits of the NHSC scholarship and loan repayment programs and (2) determin e whether NHSC has distributed available providers to as many eligible areas as possi ble. Investigators c oncluded that the NHSC loan repayment program cost s the government one half to one third less than the scholarship program. The report also found that recipients of loan repayment funds were not only more likely to complete their oblig ated service commitment than scholarship recipients, but they were more likely to stay beyond the end of their commitment. The scholarship program was intended to allow the NHSC to place health care providers in the areas with the most crit ical health care need s because the scholars enjoyed less freedom of choice when selec ting service sites. The GAO report, however, suggested that there was gene rally little difference in the priority of sites where scholarship and loan repaym ent recipients practice. Additionally, the report poin ted out that the NHSC does a poor job of allocation of provider resources based upon the health care service needs of eligible shortage areas. The awkward measuremen t criterion used often resulted in excess placements in some shortage areas and limited the governments ab ility to meet needs in others. The study did not, however, compare the scholarship program s fiscal costs and benefits to the government or to the individual (United St ates General Accounting Office [USGAO], 1995). For participants of this study, the NHSC schol arship paid for the entire cost of their training plus a taxable stipend of $1,065 per month for living expenses. Other nontaxable funds were provided to cover the co sts of books, supplies and travel. The tuition

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6 payments were also non-taxable. The scholar ship was awarded for a minimum of 2 years and a maximum of 4. Scholarships were funded based on the expe nses the scholars were expected to incur at the educational instit ution they attended. In other words, as long as the school met the NHSC criteria as an eligible, accred ited school, the amount of scholarship dollars invested was not an issue. For instance, a student at an expensive, private college could have received substantially more in schol arship dollars than a student at a more economical public university. Placement of graduates, on the other hand, was done with no regard to the amount of Federal funds invest ed in the scholars training. For example, a scholar who received only $30,000 in financia l support could have been placed at a site with a higher HPSA score, indicating a critic al need for health care services. Conversely, a scholar who received $90,000 in financial supp ort could have been placed in a site with a much lower HPSA score. This could have re sulted in a much lower potential for social return on the investment. As it was administ ered, this system failed to provide any incentive for scholars to seek out sites w ith higher need. In other words, the NHSC lacked scholarship, loan repayment or other incentive programs that definitively tied the amount and type of award to the health care needs of the communities they served. More important, there was no system in place to evalua te the returns, fiscal or otherwise, of societys investment in this scholarship program. Conceptual Framework The fiscal return on investments made in NHSC scholarship support for NPs and PAs provides a reasonable outcome measure by which data can be evaluated. This study examined the relationship between NHSC scholarship support and enhanced productivity of income and additional tax reve nues generated by the scholar.

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7 Hansen (1963) defined production valu e as the generation of wages from employment pursuits. Wage-earning activity re sults in generation of tax revenue. Positive production value then becomes the increase in wage-earning capacity due to increased employment opportunity as a result of educati on or training. As an individuals earnings increase it is reasonable to expect that th e contribution to the ta x base will increase accordingly. Within this framework, Dunn (1996) used increases in tax revenues generated to demonstrate financial returns by Pell Grant recipients receiving Associate in Science degrees. Using an approach similar to the one used in this study, he found that grant recipients repaid society for th e cost of the grant within 2 years. Because positive productivity is a direct re sult of human capital development, the concept of human capital continues to domi nate the economics of education and the analysis of labor markets. The concept of human capital refers to the fact that human beings invest in themselves, by means of education, training, or other activities, which raises their future income by increasi ng their lifetime earnings (Woodhall, 1987 p.21). Investment, or the expenditure of time or money on assets which could produce income in the future, must be distinguished from c onsumption, which requires the expenditure of time or money on goods and services to sa tisfy an immediate need but creates no potential for increased future benefit. Usi ng this framework, one could draw a working analogy between investment in physical cap ital and investment in human capital. While much has been written about measuri ng the fiscal returns of education, there was a paucity of literature examining workforce-contingent scholarship programs and the monetary returns to the indi vidual or to society. The NHSC, for example, spent a large number of Federal dollars to recruit, train, and place clinicians in medically underserved

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8 areas. But there were no effective measures being taken to track long-range production and fiscal returns. Patterns of funding should be establishe d with at least some awareness and consideration of expected retu rns to the scholarship invest ment. If the returns are not measured, it is impossible to compare the program to other reas onable alternatives. As the largest provider of scholarships for clinicians destined to work in HPSAs, the NHSC has faced numerous large changes in funding over the years. In the 1970s the corps enjoyed funding of over $140 million to provide scholarships for about 1700 clinicians annually. Following Senate hearings which revealed a default rate of nearly 20%, funding was cut to less than $10 milli on (USGAO, 1995) and scholarships dropped to about 50 per year (Shapiro, 1994). A lthough it was likely that the program had successfully delivered medical care to underser ved areas, the results were difficult to demonstrate. Without measuring such outcomes the corps will continue to be challenged to demonstrate the positive impact the scholarship program has on Americas medically underserved communities. It was important to study the NHSC schol arship program for NPs and PAs because the outcomes of these endeavors were an of ten-overlooked investment return. The scope of practice for NPCs was expanding and the roles and responsibilit ies for members of these two fairly new professions were becoming better established. Medical care organizations were responding by finding new ways to maximize their productivity. Yet many studies that examined physician workfo rce issues still did not consider the contribution of NPs and PAs.

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9 Financing Physician Assistant a nd Nurse Practitioner Training Reasons to become a physician assistant (P A) or nurse practiti oner (NP) vary. Two common reasons were for higher pay and for job satisfaction. While non-physician clinician (NPC) salaries were much lower th an those of physicians, the shorter training period resulted in much less foregone income Job satisfaction may have stemmed from the increased ability to help others or from greater autonomy in decision making. Job satisfaction also came from the flexibility to easily move from one work setting to another. Students had the expectation that these benefits would o ffset the sacrifices endured during their training years. The American Academy of Physician A ssistants (AAPA) 2003 census of new enrollees in PA programs found that among the respondents most planned to pay for their education with loans. Other popular sources of funding included personal savings, family support, grants and scholarships. Service-oblig ated sources were the smallest source of funds. While the amount of expected debt from PA training range d greatly, from $5,000 (10th percentile) to $80,000 (90th percentile), the mean amou nt of expected debt was $41,032 (American Academy of Physic ian Assistants [AAPA], 2004). The costs for nurse practitioner training were similar. Yet NPs seemed less likely to rely on loans. In a 2000 nationa l sample survey Spratley, Johnson, Sochalski, Fritz, and Spencer (2000), asked registered nurses to i ndicate all of the sources of money used to fund their education. Among the respondents, 72% of nurses pursui ng masters degrees relied on personal and/or family resources to cover the costs of tuition and fees. About 41% of the respondents received tuition reimbur sement from their employers and a little more than 20% relied on loans. Only about 20% were supported by traineeships,

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10 scholarships or grants such as the NHSC Sc holarship. Figure 1.1 is an illustration of sources used by PAs and NP s to fund their training. 0 20 40 60 80 Percent of Respondents LoansPersonal Sources Employer Tuition Grants & ScholarshipsHow PAs and NPs Pay for School PAs NPs Figure 1-1. A Comparison of Sources Used by Physician Assistants and Nurse Practitioners to Pay for Training. Adopt ed from Spratley et al. (2000) and AAPA (2003c) Some Federal programs sought to provide ince ntives for students in the health care professions with the aim of influencing them to provide medical care to underserved populations. One such program was the NHSC Scholarship Program. This program provided fiscal support to students in the form of tuition, stipends and allowances for travel, books, supplies and other reasonable ex penses. In exchange, graduates agreed to repay the debt through 1 year of service in an identified serv ice area for each year of financial support. Upon initial examination, workforce-conti ngent investments, such as the NHSC scholarship program, may appear to be noble and responsible endeavors in that they required the recipients to rep ay society for the investment made in their education. But the terms of the contract sent the implied me ssage that 1 year of service was equal in value to 1 year of scholarship support.

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11 Outcomes were, at best, haphazardly measur ed using criteria that were cumbersome and subject to misinterpretation. This result ed in duplication of placement in some areas and shortages in others. Similarly, HPSA crite ria could have been so narrowly interpreted that a doctors office could have qualified as a HPSA while the hospital across the street from the office did not. Yet, few have ever questioned the fiscal responsibility and effe ctiveness of such government programs. Perhaps because of the immense size and complexity of these programs and the departments that administered them, or perhaps due to the beneficent nature of a program designed to educate hea lth care providers and serve the great need for medical care in certain populations, the public unequivocally accepted the idea that these programs met societys needs in an efficient and responsible manner. The NHSC scholarship program was chosen for this study because its mission of providing care to underserved populations was important enough to warrant the expenditure of significant amounts of social capital and resources. But just as important was the need to identify, measure, and unde rstand variables and outcomes that could facilitate efficient investment and allocation of Federal funds. At the end of the day the question must be asked whether the large amount of time and money invested in the NHSC scholarshi p program produced a future offset through positive production. There should have been a point where it became necessary to properly account for these funds and measur e returns on the governments human capital investments. Programs not meeting some mi nimum return threshold could have been deemed too expensive to become justifiabl e. DHHS funds were designated specifically for the purpose of decreasing morbidity and mo rtality in the neediest Americans. With

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12 this designation comes the emotional baggage that makes funding cuts seem cruel and maleficent. But excessive waste of such f unds due to program mismanagement and lack of accountability would be equally irresponsible. Measuring Production It was important to determine the relevance of the NHSC scholarship to rewards and compensation in order to gain an understand ing of the benefits to society and to the individual. A number of methods could be used to estimate such benefits and returns. Fiscal Returns to the Individual Honeyman, Wattenbarger, and Westbrook (1996) described three ways to estimate the monetary yield of a college education: 1. earnings differentials 2. the net present value approach 3. private rates of return The earnings differential approach is perh aps the easiest to calculate and most rudimentary of the three. This measure describes how much mo re, on average, an individual earns than other individuals with less education. The earni ngs differential has a number of limitations. Most important, it fail s to measure preexisting differences as well as costs of education. The net present value approach attempts to estimate the present value of an education by adjusting costs and benefits to reflect the changing value of a dollar over time. The result of such analyses is a benefit/cost ratio. For example Cohn and Geske (1990) demonstrated that each dollar invested in 4 years of college yielded, on average, $1.19 for women and $1.62 for men. Interest ingly, postgraduate education dollars

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13 invested yielded $3.05 for women and onl y $1.00 for men when compared to the baccalaureate-prepared student. Estimation of the present value of a colle ge education using the net present value approach is, however, problematic in that the discount rate (t he interest rate used to determine the present value of future cash fl ows) selected by the an alyst is based on the analysts own view of the economic future. Th e net present value ca lculation is heavily influenced by the discount rate (Leslie & Brinkman, 1988). The most broadly used measure for estima ting the value of an education is the internal rate of return (IRR). The IRR is the discount rate at which the net present value calculation equals zero. By projecting a lifetime stream of earnings and costs of attendance, the IRR relates total resource costs of education to income benefits (Honeyman et al., 1996). Unlike the net present value calculat ion, the IRR is not heavily influenced by the discount rate selection. To calculate the IRR the analyst must firs t examine earnings and costs corrected to current dollars. The discount rate that would se t the earnings value equal to the cost value is the IRR. In other words, the IRR can be considered to be the relative increment of earnings associated with a given in crement of education (Mincer, 1974). The IRR is useful in that it is easy to co mpare to other potential yields. Leslie and Brinkman (1988) pointed out, however, that I RR calculations were ex tremely sensitive to the cost, as opposed to the benefits, of educa tion. They also explained that because IRR calculations compound costs forward and disc ount earnings backward the calculation tells us more about the costs of education than the benefits.

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14 They suggested that IRRs were an ina ppropriate base for making decisions about public support for higher education because the calculation is more of a reflection of how generous society has been in supporting high er education. Simply stated, society can easily influence IRRs by funding a larger share of the cost of education. This study evaluated the usefulness of continuing support for the NHSC scholarship program. Specifica lly, the study examined the le vels of income and years required to return the value of the schola rship to society. The study also allowed for generalizations to be made about the time required for payback of taxpayer funds based on starting salaries and average number of years a scholar stays in a HPSA. Fiscal Returns to Society Investments in education may also resu lt in growth of the national income. Specifically, medical education may raise labor quality by imparting greater discipline, better health, and heightened mobility. The pr actice of medicine may not only influence the amount of available labor in the comm unity, but also could impact the labor participation rate. Preventive medicine also ha s the potential to decrease costs associated with disease and therefore boost the rates of savings and investment among patients. Non-physician clinicians underwent shorte r training periods than physicians and the graduates were able to enter the workfor ce earlier. In the case of NPs and PAs, value added could be measured not only as the propor tion of clinicians em ployed as a result of training, but also by many of the same measur es that apply to the physician workforce. Investments in medical education could re sult in a number of other returns, both positive and negative. The aforementioned is merely a sample of the education-related outcomes and is by no means a comprehensive listing. Indeed, one could argue that many other intangible benefits accrue that offset monetary losses. But measurement of fiscal

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15 outcomes is important in that it allows us to understand and adjust our current practices to increase productivity, th ereby increasing the othe r benefits as well. Justification for the Study There have been no studies that address th e economic impact and ramifications to society of funding NHSC sc holarships for PAs and NPs. While a 1995 GAO report analyzed and compared costs of the NHSC sc holarship and loan repayment program, the report did not attempt to measure fiscal benefits to society or to th e individual that could accrue from these programs. Scheffler (1975) pr oduced early estimates of private rates of return for physician assistants. He found that the rates of return for this fledgling profession over 20% were comparable to those of phys icians. But these estimates were based on imprecise data. Since Schefflers 1975 study the scope of practice, salaries, and costs of training physician assistants has dram atically changed. Nurs e practitioners have experienced similar advances. Yet there was a paucity of literature describing the impact of these changes on the current prod uctivity of non-physic ian clinicians. Title VII and Title VIII of the Health Profession Service Act provided large numbers of Federal dollars to education programs for nur sing and allied health professionals through the Bureau of Health Pr ofessions and the Bureau of Primary Health Care. In 2001, approximately $460 million was allocated for health professions education, including scholarship and loan repayment funds from the NHSC. Almost $100 million of this was devoted to education programs. One of these programs, the NHSC Scholarship Program, provided $8.4 million in scholarship support to physician assistants, nurse practitioners, and certified nurse midwives in exchange for service in HPSAs (Medicare Payment Advisory Commission, 2001).

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16 Since the Federal government devoted su ch a large portion of the budget to the funding of medical education a nd since health care costs were skyrocketing nationwide, knowledge of the costs and benefits of such programs is important. Analysis of such programs could facilitate polic y change, reallocation of f unds and program modification in order to achieve the most efficient outcomes for the dollars spent. This research will show what, if any, fiscal benefits may accrue to the individual and/or society from funds received through the NHSC scholarship program. Human capital theory holds that educati on, whether formal or on-the-job, is an investment both for the individual and the society that devotes resources to providing it. Individuals deci de on how much to invest based on their expected private return, whereas governments base their decisions to invest or subsidize human capital on the social return. As an investment, education has been shown to increase a persons income even after adjusting for the costs of schooling and adjusting for differences in ability and fa mily backgrounds. For the society, there is a social return that result s from more productive indivi duals and there is a close link between education and GDP gr owth. (Langelett, 2002 p.10) This study used a sample of NHSC scholars who completed nurse practitioner or physician assistant training between 2001 a nd 2004 to determine, through statistical analysis and descriptive data, whether societ al returns justified th e scholarship program as it is presently structured and administere d. Society should expect that funds committed to the NHSC scholarship program were not wasted. Waste could be described in a variety of wa ys. It could be defined by some strictly as a lack of monetary return from an investment. Payment of Federal taxes could be viewed as a positive fiscal by-product of NP or PA training. Default of a service contract resulting in the loss of a potential health ca re provider in a medically underserved area could also be viewed as waste. In a 2001 JAMA report, Rabinowitz, Di amond, Markham, and Paynter (2001) sought to identify factors i ndependently predictive of rural primary care supply and

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17 retention and to determine which components of the Phys ician Shortage Area Program (PSAP) at Jefferson Medical College in Ph iladelphia, PA, were responsible for the outcomes. The group found a number of variable s such as having a freshman-year plan for family practice, being in the PSAP, ha ving an NHSC scholarship, being of the male gender, growing up in a rural community, and taking rural family practice electives were predictive of physicians practicing in rural pr imary care. However, they also noted that only three variables, selecti ng a rural preceptorship, growing up in a rural area, and attending college in a rural area, were univariately relate d to retention. While the study examined graduates from only a single medical school, it sheds some light on factors that could apply to health prof ession students nationwide. Over time, the characteristics of scholars who were more likely to stay in a service site beyond their service obligation were identified by the NHSC and were actively sought during the application pr ocess. Scholarship applicants were scored numerically based on the extent that they appeared to ha ve the following characteristics: (1) strong primary care post-service career goals in HPSA s, (2) experience within indigent or underserved communities, (3) understanding a nd acceptance of the mission of the NHSC and, (4) intent to participate in pre-professional clinical e xperiences in rural or urban community-based health care facilities serving HPSAs (D epartment of Health and Human Services [DHHS], 2003). Identifica tion of retention characteristics was increasingly important as each year of service beyond the initial commitment greatly increased the positive returns on the scholarship investment. The success of the NHSC provider traini ng and placement programs could be measured by how well primary care providers were placed in HPSAs. Shortage areas

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18 with the greatest need should have receive d additional emphasis and patterns of funding established with at least some awareness and consideration of expected return on investment. The assumption could be made that any given nonphysician health care provider had the capacity to create roughly th e same societal benefit to a given HPSA regardless of the institution where the clin ician trained. One could also posit that communities with the greatest need for health care services accrued the greatest benefit from any given health care provider. It woul d be only reasonable, th en, that scholarship funds were allocated with some consider ation of the HPSA of assignment for each scholar. By analyzing the fis cal costs and benefits of th e NHSC scholarship, the awards could have been administered in a way that ma de more efficient use of funds allocated to the Department of Health and Human Services. Additionally, this study examined and compar ed individual costs and benefits of the scholarship program for NPs and PAs. A fully funded 2-year scholarship program with over $26,000 in stipends plus allowan ces for books, equipment and travel expense reimbursements appears to be a good investme nt for the scholar. But foregone earnings, tax liabilities and other school-r elated expenses could have created significant differences in the degree of personal financ ial return betwee n PAs and NPs. The results of this study are important b ecause they reported the fiscal costs and benefits of funding a Federal program aimed at providing primary health care services to underserved populations in the most efficient manner possible. These results should be useful in analyzing and comp aring existing scholarship and loan repayment programs and in the development of mode ls for future programs.

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19 If the results of this st udy imply that the NHSC scholarship for PAs and NPs was an inefficient fiscal investment for soci ety, the NHSC should car efully examine how funds were distributed, how pr oviders were placed, and which methods were used to measure outcomes in underserved areas. It is en tirely possible that the number of social and global economic benefits that accrued outwe ighed financial costs. But those benefits could also have been maximized as a result of changes in the program. Limitations Upon graduation and employment the scholars enjoyed enhanced income generation abilities. This was one means of va lidating investment returns. Such income allowed the scholars to purchase additiona l goods and services as well as generate additional tax revenues. The results of this st udy reported the years of income needed to repay the NHSC scholarship program inve stment through additional tax revenues generated. It is evident that many costs and benefits, societal and personal, resulting from the NHSC scholarship program were ignored in th is study. Those costs and benefits deserve additional study. This research was limite d to monetary value considerations. There were a number of other limitations to this study. Some of these limitations include the following: 1. The study was limited to 187 participants from four selected year groups of NHSC physician assistant and nurse practitioner scholars whose demographic and financial data were available through surveys, and in government and professional associati on databases. Scholars with invalid addresses on file with the DHHS and non-respondents were not included in the study. Forty percent of potential participants di d not respond to the mail survey. 2. The study was limited to a review of i nvestment returns through increased income generation due to employment at HPSA sites following NP or PA

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20 training using NHSC scholarship funds. Additional income from related activities such as public speaking or moonlightin g was not considered. 3. The study was limited to NHSC scholars hip recipients. No comparison was made to other types of financial aid for health care providers. Similarly, income and obligations from other sources of financial aid were not considered in any comparisons. 4. Unique tax filing circumstances were not considered. For the purposes of this study a special report by the tax foundation (Moody & Hoffman, 2003) was used to estimate the average Federal tax burden on the American wage earner. Tax revenues were estimated by determining mean personal income of the subjects and applying the appropri ate tax rate for that income bracket. Marriage, divorce, adoption or other cha nges to their tax-fi ling status could influence the amount of taxes paid by each of the subjects over the period of years studied. 5. Differences in training programs betw een schools and between years at the same school were not measured. While differences and variations in individual learning experi ences are bound to exist, all of the programs are required to meet the standards of th eir respective accrediting bodies. These standards ensure that each program s curriculum is rigorous enough to produce competent clinicians capable of passing nationa l certification examinations.

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21 CHAPTER 2 REVIEW OF THE LITERATURE This research concerns the National H ealth Service Corps (NHSC) Scholarship Program; therefore the lite rature review emphasized the Federal governments involvement in education and health care. While the NHSC also awarded scholarships to physicians, dentists and nurse-midwives, this research explored the funding of education for nurse practitioners (NPs) a nd physician assistants (PAs). The Maldistribution of Health Care Providers in the United States Accurate and meaningful measurement of the U.S. health workforce has always been an enormous task. This was due, in pa rt, to the lack of consensus and varying definitions of workforce composition. The task was further complicated by the multiplicity of data sources including the De partment of Labor (DOL), Department of Health and Human Services (DHHS), and a num ber of private organizations. To add to this confusion, studies involving measuremen t of the health workforce often did not consider the roles of non-physicia n clinicians (Matherlee, 2003). The Secretary of the Department of Hea lth and Human Services has designated numerous facilities, geogra phic areas, and population gr oups as Health Profession Shortage Areas (HPSAs). These were identifi ed on the basis of agency or individual requests for such designation. The HPSA desi gnation qualified these areas for Federal aid in the form of grants, enha nced Federal insurance reimbur sements, and placement of NHSC practitioners.

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22 A Federally Qualified Health Center (FQHC ) was a type of provider defined by the Medicare and Medicaid statut es. This included all organi zations receiving grants under section 330 of the Public Health Service Act. Federally qualifi ed health centers received automatic HPSA designation. Non-automatic HPSAs were scored using a poi nt system based on four factors: (1) population to primary care physician ratio, (2) percent of the population with incomes below 100% of the poverty rate, (3) infant mort ality and low-birth weight rates, and (4) travel time or distance to the nearest av ailable source of care (Health Resources and Services Administration [HRSA], 2004b). The population to primary care physician ratio generated up to ten points and each of the other four factors ge nerated up to five points toward a maximum possible HPSA score of 25. Scholarship-eligible sites usually had a HPSA scor e of at least 15. Data used in scoring HPSAs came from a number of sources. Population and poverty data usually came from available U.S. Census information. In most cases, infant mortality/low birthweight rates came from county-level sources. Mo st facilities did not qualify for points in this category and it was unusual for any facility to score high er than one or two points. Provider data included all non-Federal provide rs without NHSC obligations or J1 visa waiver obligations. Travel time and dist ance estimates were based on Primary Care Service Area (PCSA) and Graphic Informati on System (GIS) road classification data. These were sometimes modified based on local data (HRSA, 2004b). According to a fact sheet developed by th e North Carolina Rural Health Research Program, the Department of Health and Human Services used a ratio of one primary care physician per 3,500 population or more as th e standard for a primary care HPSA

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23 designation. The same departments recomm ended ratio for an adequately served population was one primary care physic ian per 2,000 people. In 1997, over 2,000 physicians would have been required in nonmetropolitan areas in order to remove the HPSA designations. More than twice that number would have been required to meet the adequately served 2,000:1 ratio (HRSA, 1997). In 1986, Congress authorized the Counc il on Graduate Medical Education (COGME) to provide an ongoing assessment of physician workforce trends and to recommend appropriate efforts to address identified needs. The tenth report, published in 1998, examined physician distributio n in rural and inner-city ar eas. Rural areas seemed to be particularly hardest hit by shortages. Only about 9% of physicians in the United States practiced in rural areas despite the fa ct that roughly 20% of the population about 50 million people resided in rural communities (Counc il on Graduate Medical Education [COGME], 1998). The Bureau of Health Profe ssions area resource files (Dill et al., 1996) demonstrated an inverse relationship betw een county population size and primary care physicians per 100,000 residents. Counties wi th populations greater than 50,000 had over 50 physicians per 100,000 while those with fe wer than 2,500 residents had less than 20 per 100,000 residents. According to the Federal Office of Ru ral Health Policy, pe rsons living in nonmetropolitan areas were nearly 4 times more lik ely to live in a HPSA than persons in metropolitan areas (HRSA, 1997). In a repor t of conference proceedings from the 5th International Medical Workforce Conference, Gary Hart (2000) ci ted the Rural Policy Research Institute (RUPRI) to further characterize the vulne rability of rural populations. He explained that, according to RUPRI, rural U.S. populations had relatively more

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24 elderly and children, unemployment or underemployment, and poor and uninsured residents. Additionally, these populations we re more vulnerable to economic downturns than their urban counterparts. More serious, Po l (as cited in Hart, 2000) stated that during the 10th decade of the last century, the percentage of the rural population under 65 without health insurance increased 11% to approximately 7 million (15.7% of the rural population). More than 40 million adults and children in the United States were uninsured in 2000. When they sought health care, they often utilized a patc hwork of unrelated community providers who were willing to ca re for them. This included a number of hospitals, community health centers, rural h ealth clinics and a hos t of other providers. Care for the uninsured created challenges that left few resources to devote to creating an infrastructure to ensure continuity of care across providers (U.S. Congress, 2001). Ricketts, Johnson-Webb, and Randolph (as ci ted in Hart, 2000) described rural health status as generally similar to that of urban areas. He also asserted that rural residents experienced increased risks from auto, gun, and farm accidents, and exposure to pesticides and herbicides, as well as an overall increase in the prevalence of chronic disease. HPSAs were designated and ranked according to a number of statistics, namely, the availability of health care providers. The ratios used to designate HPSAs did not, however, consider contributions made by heal th care providers who were not physicians. Data definitional problems and differences in State laws also made estimation of nonphysician Clinician (NPC) impact on the health care workforce difficult. Yet NPCs, such as physician assistants and nur se practitioners, were becoming increasingly important

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25 providers of medical care services. As of 2003, approximately 110,000 PAs and NPs comprised approximately one-sixth of the physician work force. Their productivity and range of services approached 90% of what a primary care physician provided. The supply of NPCs was increasing. As of 2002, the a nnual number of PA and NP graduates had risen to 12,000. This number rivaled the 17,000 medical graduates produced each year (Hooker, 2003). Cooper, Laud, and Dietrich (a s cited in Hart, 2000) estimated that the number of trained nurse practit ioners would nearly double by 2015. Gamm, Castillo, and Pittman (2003) asse rted that non-physician clinicians appeared to slightly favor rura l settings, provided needed primary care, and in most cases, costed less and were better able to conform to the resource constraints in rural areas than physicians. Baer and Smith (as cited in Gamm and Pittman, 2003) made the point that among the 55,730 active nurse practitioners and 31,084 physician assistants in 1996, a large percentage practiced in rural or urban settings. NP s and PAs in rural settings numbered 24.72 and 11.91 per 100,000 populatio n, respectively; for the urban populations the numbers were slightly smaller at 20.08 and 11.66, respectively. Very little research has been done to examine characteristics of non-physician clinicians and their decisions to practice in non-metropolitan versus metropolitan areas. Many of the same factors that influenced physicians may ha ve also shaped the location decisions of non-physician clinicians and th eir dedication to pract ice in underserved areas. Rabinowitz et al. (2001) found that ha ving an NHSC scholarshi p, being of the male gender, and taking an electiv e senior family practice rural preceptorship were independently predictive of physicians practicing in rural primary care. In their study,

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26 participation in a physician shortage area program was the only independent predictive factor of retention. A study by Fowkes, Gamel, Wilson, and Garc ia (1994) suggested that older PA and NP students who clearly identified practi ce goals and had bac kgrounds in underserved areas were more likely to practice in such ar eas after graduation. It also seems plausible that clinicians with families would have been more likely to remain in one geographic location as children attended schools and developed circles of friends. Characteristics of the site, such as sc ope of practice, turf conflicts, and reimbursement issues were also important to physicians. It is reasonable to assume that many, if not all, of these factors applied to PAs and NPs. Additionally, acceptance of non-physician clinicians by the local medical community may have played an important role in NPC retention. From the literature it appears that re imbursement was not a strong incentive for clinicians serving in non-metropolitan areas. A report by the Federal Office of Rural Health Policy (1996) asserted that non-metr opolitan physicians derive d a larger share of their gross practice revenue from public program s that pay lower rates, such as Medicare and Medicaid. Conversely, metropolitan physicia ns served more patients with higher paying private insurance. Commonly used indicators of physician work load in 1995 indicated that non-metropolitan physicians worked longer ho urs and had more patient visits per week than their metropolitan c ounterparts (Federal Of fice of Rural Health Policy, 1996). In a National Health Policy Forum B ackground Paper, Karen Matherlee (2003) provided a comprehensive view of the structure of the health workforce as well as public

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27 and private insurance coverage and payment po licies. Her assertion was that the health workforce follows the dollars of public (M edicare and Medicaid) and private insurers. She described Medicare as th e standard bearer for many private insurers. Medicare covered eligible persons ove r 65 and younger people with qua lifying disabilities. This made Medicare the largest payer for most hos pitals and many practit ioners and therefore a major influence on the health workforce. Reimbursement for services provided al so impacted a providers decisions regarding practice location. Cert ain practitioners could recei ve direct payments from Medicare and others could not. Accordi ng to a 2002 Medicare Payment Advisory Commission report to Congress (as cited in Matherlee, 2003), nurse practitioners received 75-85% and physician assistants r eceived 85% of the physician fee when they provided services within thei r legal scopes of practice. If however, they provided these services under the direct s upervision of the physician they billed directly under the physicians number (billing inci dent to physician services) at 100% of the fee schedule. Medicaid, a Federal-State entitlement program for certain persons and families with low incomes and resources, was another larg e source of funds to health providers in underserved areas. This public program allowe d states a great deal of flexibility to administer their own plans. The Federal government provided matching funds to the states and outlined certain requirements. A states Medicaid program was must to offer medical assistance for certain basic services to most categor ically needy populations. (Matherlee, 2000, p.11) Matching funds were al so available for 34 optional services. Some states have undertaken initiatives to give different types of incentives to practitioners who selected certain specialty and practice locations. Because the states had

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28 considerable flexibility in program administra tion, there was great variation from state to state in a practitioners lega l scope of practice and paymen t rates. All State programs covered medical services provided by NPs a nd PAs in fee-for-service and managed care plans either at the same rate or a lower ra te than was paid to physicians (Matherlee, 2003). The Use of Non-Physician Clinicians At the time of this study, non-physician cl inicians were well into their fourth decade of history in American medicine. Th ey were employed by over one-quarter of all group practices and provided a major source of access in many large health maintenance organizations (Hooker, 2003). The physician assistant and nurse practitioner professions we re initially created as a strategy to address health care needs cause d by a nationwide shortage of physicians. Many practices later employed them for a number of other reasons. Non-physician clinicians were trained in a much shorter period of time at a much lower cost than physicians. When this was coupled with the lo wer salary ranges, these clinicians became a cost-efficient way to improve th e productivity of a practice. An analysis by the U.S. Congress Office of Technology Assessment concluded that within their areas of compet ence, nurse practitioners and physician assistants provided health care whose quality was equivalent to that of care provided by physicians. Further, some studies indicated that these midlevel practitioners were more adept at providing supportive care, health promotion activit ies and services that depended on communication with patients (U.S. Congress, 1986). More important, an NPC could handle rout ine office visits, see acute patients quickly, provide in-depth patient education, an d perform a number of other routine tasks,

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29 freeing the physician to concentrate on more complex cases, handle practice management tasks, or just spend a few extra hours each week at home. Many practices used NPCs to handle ove rflow of patients and cover scheduled appointments when the physician was called away from the office for emergencies. Their flexibility and willingness to shift where demand for medical services was greatest made them an asset in a medical practice envi ronment that was rapidly evolving. Other practices used NPCs to boost productiv ity and augment clinic services. But a study by Shi, Samuels, Ricketts, a nd Konrad (1991) examined major factors influencing the use of NPCs in rural comm unity and migrant health centers based on national survey data. The study demonstrat ed a significant but inverse relationship between the number of physicians and the number of NPCs employed. This finding suggested that NPCs primarily served as s ubstitutes for physicians in rural community and migrant health centers. In many work settings nurse practitioners and physician assistants provided comparable services and enjoyed similar scope s of practice. Yet the differences between the advanced nursing practice approach used by NPs and the medical model employed by PAs also allowed these two groups to offer a more diverse array of health care services when working side by side. With this in mind, it is useful to highlight the characteristics of the two professions. Nurse Practitioners Nurse practitioners were registered nu rses (RNs) with advanced academic and clinical experience. They were trained to take principal re sponsibility for the diagnosis and management of uncomplicated illness either independently or as part of a health care team. NPs provided a full range of primary care services in the community setting and

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30 made decisions about their patie nts nursing needs. In some st ates, they had the authority to independently prescribe medications. They were able to spend more time with their patients and provide education and counseling on wellness and disease preventi on. Some nurse practitioners developed and implemented community programs dealing with issues such as self-help or group therapy, parenting, nutrition, and stress reduction. Many worked under the supervision of a physician. In their practice they often collaborated with other health care professionals on matters regarding patient care. Their clinical knowledge and experience as RNs, coupled with their advanced clinical training, enables NPs to work with patients on a wide range of clinical tasks. NP practice blurs the disc ipline boundaries between nursing and medicine so their services can both substitute for and complement the care of physicians (HRSA, 2004a p.4). Profile In 1992 there were approximately 28,000 NPs practicing in the U.S. In an 8-year period the number rose 240% to more th an 95,000 in 2000 (HRSA, 2004a). By 2004 there were 106,000 NPs pract icing in the U.S. (Ame rican Academy of Nurse Practitioners [AANP], 2004). Approximately 96% of NPs were female and their mean age was 46. About 85% of them worked in primary care. Approximately 58% of NPs worked more than 32 hours per week (Hooker, 2003). Training The typical training program ranged from 15 to 36 months in length (with a mean of 26 months.) In 2002 these programs produc ed almost 7000 graduates. The programs taught assessment, diagnosis and intervention as an extension of nursi ng practice. At least 80% of NPs graduated with a masters de gree (Hooker, 2003). Accord ing to a report by Nurse Practitioner Alternatives (NPA), over 83 % of nurse practitione rs were certified in

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31 family and adult advanced practice nursing (Nurse Practitioner Alternatives [NPA], 2004). By the end of the 20th century there were 321 institutions sponsoring nurse practitioner training programs. Around 72% of the graduates of these programs trained in primary care disciplines such as adult, fam ily practice or pediatrics. Nurse practitioner education programs were accredited by the National League for Nursing Accrediting Commission, the National Association of Nurse Practitioners in Womens Health, and the Commission on Collegiate Nursi ng Education (HRSA, 2004a). Scope of Practice Most states required NPs to pass an examin ation from one of four certifying bodies; the American Academy of Nurse Practiti oners (AANP), the National Certification Council for the Obstetric, Gynecologic a nd National Nurse Specialties (NCC), the American Nurses Credentialing Center (ANCC) or the National Certification Board of Pediatric Nurse Practitioners and Nurses (NCBPNP/N) (American Association of Colleges of Nursing [AACN], 2005). Clinical activities for NPs were usually regulated by the State Board of Nursing. In nursing care functions, NPs were professi onally autonomous. Most states, however, required them to work in collaboration with a physician. They were allowed to practice independently in 16 states, and in 10 of t hose they prescribed independently (Hooker, 2003). The roles, responsibilities and privileges of NPs vari ed greatly depending upon the jurisdiction in which they practiced. In many states, the legislati on defining scope of practice treated PAs and NPs fairly equally. But some states treated them unequally,

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32 providing a competitive advantage for one pr ofession over the other (Wing, Langelier, Continetti, Slocum, & Salsberg, 2003). Salaries A 2003 national salary of nurse practitione rs showed the average salary as $69,203 for full-time nurse practitioners. This wa s up 9.55% from the $63,172 average in 2001. The survey also demonstrated differences based on practice setting. NPs working in urban areas fared best, with salaries averaging $70,040, followed closely by those working in suburban areas, who made an av erage of $69,835. Nurse prac titioners in rural areas reported an average sa lary of $66,842 (Tumolo & Rollet, 2004). According to the same survey, masters-prepared NPs made only around $1,200 per year more than those with bachelor degrees ($67,951 and $69,144, resp ectively). Those with doctoral degrees who worked outside of academic settings earned $77,243. Work Settings In 2004, almost 60% of NPs were practic ing in ambulatory settings, including HMOs, school health, and private clinics and offices. Among these clinicians, 4.7% described their practices as independent (NPA, 2004). Productivity Nurse practitioners averaged about 75 out patient visits per week (Hooker, 2003). Hooker also asserted that productivity of non-physician clinicians (NPCs) in a managed care setting was generally 10% higher than phys icians in a similar or same setting. He further explained that this was due to the co llateral roles and hosp ital responsibilities of physicians that took them away from the clinic.

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33 According to a 2004 report (NPA, 2004) the majority of NPs saw between 11 and 15 patients per day. Only 21% of nurse prac titioners surveyed reported more than 20 patient encounters per day. Physician Assistants Physician assistants (PAs) were trained to provide health care services under the supervision of physicians. The le vel of supervision, direct or indirect, varied depending on experience, the task perfor med, the legal environment and practice setting. PAs should not be confused with medical assistants, w ho performed routine clerical and clinical tasks. Physician assistants performed diagnos tic, therapeutic, a nd preventive medical tasks as delegated by their s upervising physician. This may ha ve required them to take medical histories, perform physical examin ations, order laboratory tests and x-rays, diagnose illnesses, and prescribe medications PAs also treated minor injuries by suturing, splinting, casting, and performing other therapeutic procedures. Patient education and counseling was another important service provided by physician assistants. While PAs worked under the supervision of a physician, they were sometimes the principal provider in clinics where a physic ian was only occasionally present or was primarily available by phone. PAs consulted with their supervising physician or other health care professionals as needed or re quired by law. The duties of the PA were determined by the supervising physician in accordance with State law (U.S. Department of Labor, 2004). The American Academy of Physician assist ants (AAPA) estimated that there were approximately 61,871 individuals eligible to practice as physician assistants during 2004. Physician assistants pr acticed in at least 61 specialty fields. Acco rding to a 2004 census, 42% of the respondents reported their primary sp ecialty as one of the primary care fields:

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34 family/general practice (30%), general in ternal medicine (8%), obstetrics/gynecology (3%), and general pediatrics (3%). Other prevalent specialties included emergency medicine (10%), surgery (23 %), and internal medicine s ubspecialties (10%) (AAPA, 2004). Profile In a 2003 census of new enrollees in physician assistant programs, females accounted for 71% of respondents. The mean age of the newly enrolled students was 28.1 years. Three fourths had no de pendents at the time of the census; one fourth report at least one dependent. The census also reveal ed that 76% of respondents were students during the 12-month period prior to PA school. Half of these were full-time students and half attended part-time. Approximately 58% were previously employed full-time in a health care field. In 2002, the average pre-PA student had worked 3.1 years in a health care field with direct patient contact prior to PA school (AAPA, 2003a). Education levels of new a pplicants ranged from high school diplomas to doctoral degrees with 89% of respondents having 4 y ears or less of college. PA students come from a wide variety of backgrounds. Unlike nurse practitioner students who were all nurses prior to matriculation, PA students came from a number of medical-technical positions such as EMT/paramedic (17%), medical assistant (17%), emergency room technician (8%), and phlebotomist (9%). Only about 4% of PA stude nts were registered nurses. Other types of nurses account for 8% of PA students (AAPA, 2003c). Physician Assistant Training In 2002 there were 133 accredited physicia n assistant training programs in the United States. Among these programs, 68 of them offered a masters degree. The rest offered a bachelors or an a ssociates degree. Most applican ts (79%) to PA programs in

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35 2003 had already earned at least a bachelors degree (U.S. Department of Labor, 2004). Despite the variety of degrees offered, most PA program curri cula were very similar in structure and length. Physician assistant training programs usually lasted at least 2 years and included classroom instruction in biochemistry, clin ical pharmacology, clinical medicine, human anatomy and physiology, disease prevention and medical ethics. Similar to medical students and residents, PA stude nts obtained supervised clinical training in several areas, including primary care medicine, inpatient me dicine, psychiatry, surgery, obstetrics and gynecology, geriatrics, emergenc y medicine, and pediatrics. Some PAs pursued additional education in specialties such as surgery, neonatology, or emergency medicine. PA pos tgraduate training programs were also available in areas such as internal medicine, rural primary ca re, emergency medicine surgery, pediatrics, neonatology, and occupational medicine. All states required graduates from accred ited PA programs to pass the Physician Assistant National Certifying Examination (PANCE) to become eligible to practice. Afterwards, they were required to log 100 hour s of continuing medical education every 2 years and pass the Physician Assistant Na tional Recertification Examination (PANRE) every 6 years. Salaries Physician assistant sa laries vary by location, specia lty, and years of experience. According to a 2004 census by the American Academy of Physician Assistants, the median annual income for physician assistants with an average of 6 years of clinical experience was $74,264. This was up from $65,783 th e previous year. In dividuals in the 10th percentile earned $57,823 while t hose in the 90th percentile earned $103,614.

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36 Approximately 24% of respondents reported r eceiving some type of bonus or incentive pay and 18% received overtime pay. Other forms of reported compensation included funds for malpractice insu rance, licensing, credential ing, professional dues and continuing medical education. Respondents who graduated in 2003 reported a median starting salary of $65,783. This was an increase from the previous year survey amount of $63,437 (AAPA, 2004b). Scope of Practice Depending on the setting, physician assistan ts could perform roughly 80% of the routine tasks that physicians normally perf orm. These tasks included obtaining medical histories, performing physical examinations and diagnosing and treating illnesses and injuries. They also performed a number of pr ocedures such as sutu ring, lumbar punctures, thoracenteses, paracenteses, and central line placements. PAs worked under the delegated authority of a physician and they were not allowed to perform tasks that were not within the scope of practice of their supervising phys ician. The scope of practice in some states was very broadly defined; other states restrict ed the scope of practice in such detail that performance of routine tasks was limited. Work Settings PAs worked in a diverse array of settings From military battalion aid stations, hospitals, and correctional institutions to priv ate practices, community health centers, and inner city clinics, almost one fourth of PAs were located in rural and frontier communities (Cawley, 2002). In 2004 only 8% of practicing PAs worked in Federally Qualified Health Centers, correctional facilities or other community health centers. Of the respondents practicing in

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37 fields generally in demand at HPSA clinics, 30% practiced in family/general medicine, 3% in general pediatrics, and 8% in ge neral internal medi cine (AAPA, 2004). When new enrollees to PA programs were asked about an intended specialty area, only 40% indicated family/general practi ce and 26% were undecided. Approximately 80% of respondents indicated that they w ould be willing to practice in a medicallyunderserved area, yet only 32% expressed an in tention to practice in such areas (AAPA, 2003a). Productivity Roughly 88% of PAs worked more than 32 hours and averaged about 105 patient visits per week. In a report on non-physician clinicians in the U.S ., Hooker (2003) cited a medical group management association (MGMA) survey that described the compensation-to-production ratio, (the salary and benefit cost to employ a provider compared to the revenue generated from thei r services.) This ratio was 0.38 for PAs, 0.41 for NPs, and 0.49 for family physicians. This was, perhaps, because PAs were paid substantially lower salaries than physicians and they saw a comparable number of patients per day. This made NPC utilization quit e profitable for health care organizations at certain levels of medical care. The MGMA survey data also indicated that for every dollar a PA generated, 26 cents went to pay the PA (Medical Group Management Association (MGMA) as cited in Hooker, 2003). Larson, Hart, and Ballweg (2001) estima ted the productivity of a nationally representative sample of PAs at 83% of that of physicians. They reported that the PAs performed 61.4 outpatient visits per week compared to 74.2 visits performed by physicians. The authors go on to say that ru ral PA productivity was higher than urban productivity due to the concentration of generalist PAs in rural settings.

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38 Assistance to Health Prof ession Shortage Areas Since the 1970s financial support for the educ ation of health care providers to serve in shortage areas has been provided primar ily through a few foundati ons and a number of government programs. Some programs were designed to facilitate the training of new health care providers or to influence them to practice in shortage areas. Other programs improved reimbursement for existing hea lth care providers in underserved areas. Medicare The role of Medicare in (1) funding of Graduate Medi cal Education (GME) and (2) enhanced reimbursement played an enormous role in the preparation and support of health care providers serving HPSAs. Direct GME funds cove red residents salaries and fringe benefits, allocated hospital overhead connected with training programs, and other costs. Indirect GME dollars were added to inpatient prospective payment of diagnosisrelated group rates in order to recognize the additional costs teaching hospitals incur as a result of their teaching programs. Accordi ng to Matherlee (2003), Medicare GME outlays in 2000 were approximately $7.8 billion. Medicaid Medicaid was a Federal-State entitleme nt program aimed at low-income and resource-poor individuals. While states we re required to offer medical assistance for certain basic services to most categorically needy populations, the sy stem provided states with a great deal of flexibility to administer plans in ways that best met the needs of their recipients. Matching funds were also available for a number of optional services. Under Federal-State arrangements, states were responsible for purchasing health care services and paying hea lth care providers. Most states however, contracted with health plans under managed care arrangements. The flexibility of the program allowed a

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39 number of states to create incentives for pr actitioners who selected certain specialty areas and practice locations. Payment rates and legal scopes of prac tice varied from state to state (Matherlee, 2003). According to Hein rich (USGAO, 2000) Me dicaid became the largest source of health care revenues for co mmunity and migrant health centers. In 1998, health centers reported re venues of almost $3 billion. Foundations and Trusts For many years the W. K. Kellogg Foundation, the Pew Charitable Trusts, and the Robert Wood Johnson Foundation offered phila nthropic support to programs that sought to improve the availability of commun ity-based medical care and primary care practitioners (M atherlee, 2003). The W.K. Kellogg Foundation was created in the 1930s to prepare health care providers with the values, skills, and perspe ctive associated with promoting health and preventing illness and with community in its broadest sense. Since then the Foundations programs brought together educational institu tions with community-based organizations to improve health professions education. The Pew Charitable Trusts embarked on a four-part strategy to appropriately train health care providers and improve the provi sion of primary and population-based health care. The strategy involved defining the syst em and the roles and responsibilities of the practitioners, determining fi nancing changes necessary to support shifts in training, redirecting training to community-based out patient settings, and educating the public about primary care services and how to use them more effectively. The Robert Wood Johnson Foundations programs related to primary care workforce development covered several cat egories. These included training and leadership development, enhancement of generalist physician training programs,

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40 development of primary care practice in comm unities, and improvement of diversity of the health care workforce (Matherlee, 2003). Public Health Service Act The Federal government, through Titles VII and VIII of the Public Health Service Act (PHSA) supported a number of efforts aime d at training health pr ofessionals to serve in shortage areas. Title VII covered medical, dental and allied health. Title VIII covered general and advanced practice nursing (Mathe rlee, 2003). A number of initiatives fell under the umbrella of these two titles: The Minority and Disadvantaged Health Pr ofessions Initiative provided support to health professions and scholarships to disadva ntaged and minority students who attended a health professions or nursing school. Th is included Centers of Excellence Programs, the Health Careers Opportunity Program, the Scholarship for Disadvantaged Students Program, and the Faculty Loan Repayment Program. Primary care medicine and dentistry progr ams promoted training of practitioners including general pediatricians, generalists in internal medicine, family physicians, dentists, and PAs. The Geriatrics Health Pr ofessions Program suppor ted geriatric faculty fellowships, entry of geriatric physicians into academic medicine, and geriatric training in schools. The Quentin N. Burdick Program for Rural Interdisciplinary Training strengthed the distribution, diversity, a nd quality of health care practitioners by providing opportunities for collaboration among academic in stitutions, rural health care agencies, and health care professionals. The National Center for Health Workforce Analysis collected and analyzed data on the health care workforce in an effort to help State and local planners. The center

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41 conducted workforce issue analyses, evaluate d training programs, and conducted research on the health workforce. The PHSA, through Title VIII, provided fo r public health workforce development, nursing education initiatives and nursing workforce development as well as loans for needy and disadvantaged medical an d nursing students (Matherlee, 2003). Area Health Education Centers The Health Resources and Services Admini stration (HRSA) encouraged students to take advantage of training opportunities by serving the health car e needs of underserved communities. This was done with financial support to Area Health Education Centers (AHECs) as authorized by the PHSA. These centers served the communities by extending the resources of academic health cente rs into rural areas and providing clinical training opportunities for health professions and nursing students (National Rural Health Association [NRHA], 2003). The AHEC initiative enjoyed great success since the inception of the first generation of centers in 1972. A second gene ration of AHECs began in 1977, followed by a third generation in 1984. Unlike the firs t-generation AHECs, subsequent generations placed greater emphasis on non-physician c linician education (Bernstein, 1990). Each of the AHECs was eligible for Federa l funding for up to 9 years. During this time State and local governments contributed at least 25%. The goal was to eventually function without Federal funding. As of 1998, over 23 AHEC programs were functioning without Federal funding and eighteen more were moving toward independence. The AHECs differed greatly in their unique goals and priorities. These centers were involved in a wide variety of activities designed to m eet the needs of the local populations and the students. In Southwestern border-states they emphasized recruitment

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42 of health professionals to serve Hispanic communities while others targeted Native American and Black populations Urban AHECs often concentr ated on graduate medical education, health profession career opport unities, undergraduate medical education, health education and nutrition programs. Rural AHECs, on the other hand, emphasized nursing education and continuing professiona l education, and provided strong support for area NHSC clinicians. The continued success of the AHECs resulted in a relatively stab le funding history. As of 1990, appropriations for these progr ams totaled $18.5 million. The decentralized clinical education experiences made possible by the AHECs provided confirming education for health professionals in remote communities. These experiences often influenced health care providers to make the decision to serve in a HPSA after graduation (Bernstein, 1990). National Health Service Corps Initially enacted by the Emergency Hea lth Personnel Act of 1970 to respond to geographic maldistribution of primary care pr ofessionals, the NHSC was later authorized under Title III of the PHSA. The NHSC, whic h offered scholarship and loan repayment dollars in return for obligat ed service in shortage areas has gone through periods of fluctuating fiscal support. In 1972, the NHSC scholarship program was created, followed by the loan repayment program in 1987. The NHSC loan repayment program was accompanied by a State Loan Repayment Program created in the same year. Under the State Loan Repayment Program, states were encouraged to create loan repayment programs similar to the NHSC program. The Department of Hea lth and Human Services was to then fund up to 75% of the total costs through a grant to the state.

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43 The 1980s were particularly hard year s for the NHSC scholarship program. Appropriations fell from $63.8 million in FY1981 to $0 in FY1989 and FY1990. In 1987, Congress initiated the NHSC loan repaym ent program under which the Corps would repay educational loan obligati ons incurred by health care pr ofessionals in exchange for obligated service in HPSAs. The 1990s saw a revitalization of the programs and the number of HPSA designations increased dramatically. Be tween 1990 and 1994, Congress increased NHSC program funding in response to an increase in the number of HPSAs. As a result, the number of health professionals with scholarship obligations increased precipitously and the funding continued to increase in th e years following, from $112.4 million in FY1998 to $115.3 million in FY1999, $116.9 million in FY2000, and $125 million in FY2001. However, this still met less than 13% of the current need for primary care clinicians in HPSAs (U.S. Congress, 2001). In FY 2002, $90 million in NHSC scholarships and loan repayments were awarded to health care clinicians (Duke, 2002). The scholarship program remains a vital piece of the NHSC package. As a result of the Public Health Service Act, at least 40% of NHSC funding was required to be used for scholarships (USGAO, 2000). In 2003 an estimated 522 new and 70 continuing scholarships were awarded, obligating roughl y $39.6 million. The total estimate for FY 2004 was $57.2 million (NHSC, 2004c). Economic Incentives for Community Health Centers In addition to financial support for educati on of health care provi ders, a number of economic incentives were available to esta blish and maintain th e community health centers that provided training and future employment opportunities to students. Barnes et al. (2004) outlined six strong economic incentives for these organizations. These include

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44 (1) Section 330e grant funding, which allowe d communities to receive up to $650,000 in Federal grant dollars to establish and operate health centers; (2) malpractice insurance coverage under the Federal Tort Claims Act; (3) access to medicines at a discounted rate through the 340B drug pricing program; (4) Enhanced Medicaid reimbursements; (5) State and local funding and donations; and (6) health care provider recruiting assistance through the NHSC. Federal Support for Higher Education In accordance with the tenth amendment of the U.S. Constitution, responsibility and authority for funding higher education belongs to each of the 50 states. But the Federal government has a long and diverse history of increasing support for higher education. This history is marked by a num ber of significant events. A few of these milestones deserve mention in that they help build an understanding of the current Federal financial aid environment. Beginni ng with the Land Grant College Acts of 1862 and 1890, Federal support has served to stimul ate the growth of public higher education in the United States. These Acts also forged a link to economic development of the industrial classes thr ough higher education. Following the Second World War, the Servicemans Readjustment Act of 1944, also known as the GI Bill, opened the door to a broad middle class that built upon the research partnerships that had develope d between the Federal government and higher education. The benefit covered all tuition, book s and fees along with a monthly stipend. In the peak years of the program the cost s amounted to $2.7 billion, almost 1% of the gross national product. According to Pris co, Hurley, Carton, & Richardson, (2002), the GI Bill marked the emergence of the most significant Federal role in higher education and set in motion the growth and expans ion of numerous public institutions.

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45 In the late 1950s the launch of Sputnik by the Soviet Union started a space race which resulted in the creation of the Nati onal Defense Student Loan (NDSL) program. The program, which sought to increase the U. S. supply of scientists and teachers by forgiving up to half of a students loan in exchange for service teaching science, math, or a foreign language, later became known as the Perkins loan program (Shapiro, 1994). In 1964 the civil rights act, Title IX of the Education Amendments of 1972, and the Americans with Disabilities Act of 1991 ope ned the doors to even more Americans. Higher education institutions continued to res pond to calls for divers ity inspired by these changes. In 1965 President Lyndon B. Johnson si gned the Higher Education Act which sought to ensure access to hi gher education institutions fo r high school seniors regardless of their financial status. Backed by an unprecedented $804 million, the bill effectively shifted the focus of Federal support from areas defined as national priorities to those of community service, continuing education, library assistance, and teacher programs (National Education Admi nistration [NEA], 2003). The Federal government also supported higher education th rough a number of student assistance programs, tax policies, and research support. Following the NDSL program of 1950s, the 1960s saw several program s emerge that were designed to fight the war on poverty. Through the Guaranteed Student Loan program, for instance, the Federal government guaranteed loans to economically disadvantaged students. Similarly, the Supplemental Educational Opportunity Gran t (SEOG) program distributed funds to institutions of higher educati on to provide grants to needy undergraduate students. In the

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46 1970s, the largest Federal gran ts program in history, the Pell Grant program, began making grants available to undergraduate students in need (Prisco et al., 2002). In addition to the numerous loan and grant programs, a number of tax programs were favorable towards institutions and th eir students. Wolanin (NEA, 2003) estimated that Federal tax benefits afforded to institutions of higher learning could be valued at approximately $50 billion per year. Individual tax credits could be appreciated in the form of tax-free scholarships as well as tax credits and deductions. The Taxpa yer Relief Act of 1997 created one of the largest and most expensive ta x benefit programs for higher e ducation expenses in history. Conklin (as cited in NEA, 2003) described the resulting Hope tax credit as a program so large that when taxpayers fully use the tax cr edits, the cost to the government could easily exceed the cost of all other existing Federal financial aid programs combined. Research support was another large s ource of funding for U.S. colleges and universities. According to a 2002 American A ssociation for the Advancement of Science intersociety working group report (as c ited in NEA, 2003), Federal sources were responsible for $17.5 billion of funds for research in higher education. The lead supporters of research funding for highe r education were the National Science Foundation and the National Institutes of Health. Despite the appearance of an enormous increase in support for higher education, McPherson and Shapiro (1997) contended that State governments have been decreasing the appropriations to public colleges and universities and that the burden of college costs had been shifted to students and families th rough increased tuition. They pointed to a 26% increase in tuition in 1979-1980 and a 35% rise in 1992-1993. They further

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47 explained that higher costs were restricti ng college options for some lower income students and that Federal stude nt aid programs failed to ke ep pace with the increases. Recent Federal Involvement in Higher Education A 2001 report to the U.S. Department of Education (U.S. Department of Education, 2001) stated that Federal suppor t for education, excluding estimated Federal tax expenditures, was over $128 billion in FY 2001. The report further pointed out that Federal support for education increase d 56% between FY 1990 and FY 2001. Of the estimated $678 billion in direct expend itures by schools and colleges in FY 2001, over $77 billion was in the form of revenues from Federal sources. The 1992 reauthorization of the Higher E ducation Act dramatic ally changed the landscape of student financial aid and de bt burden. Choy and Li (2005) described dramatic increases in Federal borrowing due to the increased loan limits and eligibility for Stafford loans and the introduction of the unsubsidized Stafford loan. They assert that after adjusting for inflation, the Federal loan volume increased 137% in the decade following the reauthorization. The amendment al so increased family income eligibility limits for Pell Grants. Part-time students b ecame eligible as well (Prisco et al., 2002). 1993 saw the Student Loan Reform Act dr amatically expand the direct loan program from 100 to 1000 institutions. During th e same year, the National Service Trust Act created Americorps and established a national service trust offering individual grants of nearly $5,000 annually for college co sts in exchange for each year of full-time community service (Prisco et al., 2002). Choy and Li (2005) also pointed out that the percentage of bachelors degree recipients who had borrowed money from a ny source to finance their undergraduate education increased from 49% in 1992 to 65% in 2000. Graduate student borrowing

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48 increased from 67% to 72% for dependent students during the same period. More important, they concluded that higher salaries low interest rates, and loan consolidation programs resulted in increased overall debt without substantially increasing the debt burden (monthly loan payment as a percentage of monthly income). Zuckman (1991) added that students received fewer grants in the 1980s and into the 1990s. He reported in Congressional Quarterly Weekly that 80% of all Federal financial assistance in 1975 came from grants. By the early 1990s that figure had dropped to 49%. President Clinton (1997) began his second te rm with a State of the Union Address that declared educational reform his top pr iority. As a result, the 1997 Taxpayer Relief Act called for an increase in Federal grants to low-income undergra duates (Kane, 1997) and $38.4 billion in education tax cuts over 5 years. This included the HOPE Scholarship tax credit, a Lifelong Learning Cr edit, and elimination of pena lties for IRA withdrawal if funds were used for postsecondary educa tion. Many argued that these tax credits benefited primarily middle-income students at higher priced institutions and neglected lower-income students (Prisco et al., 2002). Similarly, Thomas Kane (1997), who estim ated the cost at approximately $48 billion over 5 years, asserted that the tax cuts were poorly targeted and could be abused for leisure-oriented coursework. He also cl aimed that the plan would do little to reduce the cost to families of future tuition increases. He recommended greater reliance on income-contingent loan forgiveness as an alternative way to help families pay for college. Since the Land Grant Acts and the GI Bill, the Federal role in higher education support has greatly expanded. By increasin gly manipulating the terms under which

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49 Federal resources were made available, th e Federal government developed substantial influence over higher educati on behaviors and outcomes. Federal Support for Medical Education Medical training in the United States e volved from an endeavor largely funded by tuition, fees, endowments, and appropriati ons to one supported by research grants, contracts, and clinical pract ice (Abrahamson, 2000). As f unding sources and priorities changed, the activities of medical studen ts and the roles of faculty changed. In the 19th century and through the firs t 10 years of the 20th century, medical education was very poorly funded. According to Shyrock (1947), theological schools received $18 million in total endowments. Medical schools received only half a million. In the years following Abraham Flexners gr illing review of medical education in the United States, medical schools began to receive hundreds of millions of dollars. Many of these funds came from national foundations such as the Carnegie Corporation and the General Education Board. These were added to already generous contributions from private philanthropists (Ludmerer, 1999). Following World War I medical schools grew enormously. This growth was partly fueled by advances in medical research. Research evolved from an activity whose purpose was to enhance teaching to one that promised to solve the medical problems of the world. During the 20th Century, the number of medical discoveries in France, Britain, and Germany began to decline, but the United States experienced dramatic research breakthroughs in a number of fi elds. While some U.S. medical schools generated modest funds from faculty practice, research was clearly at the forefront of means for generating revenue in U.S. medical schools.

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50 When Medicare and Medicaid legislation was enacted in 1965, the emphasis for revenue sources slowly began to shift from re search to medical service. For instance, in the early 1960s, every dollar generated from medical service was matched by 4.7 dollars from medical research. By the late 1970s, the ratio had become 1:1 and by the early 1990s U.S. medical schools received two dollars of revenue from clinical practice for every one dollar from research (Ludmerer, 1999). Clinical practi ce was clearly becoming the cash cow for medical schools. Federal Funding of PA and NP Training Non-physician clinician training programs experienced a diffe rent history of financial support. These programs were almost exclusively dedicated to education with a small amount of faculty practice activity. Sinc e their inception in the late 1960s, the nurse practitioner and physician assist ant professions gained great momentum and support from Federal programs aimed at improving access to medical care for underserved populations. While many of their respectiv e training programs were conceived primarily with soft money from grants, the duration of these sources of funding was usually limited; schools were pressed to find more durable st reams of revenue in the future. Title VII of the Public Health Service Act authorized competitive grants for the training of physicians, physician assistants, de ntists, and other health professionals. Title VIII programs supported nursing education. Unde r these titles, the Bureau of Health Professions (BHPR) administer ed about 40 grant programs. In fiscal year 2001, Title VII programs allocated $4.0 million to accredited schools to meet the costs of planning, developing, and maintaining programs to train physician assistants in primary care medicine. In the same year, Title VIII programs appropriated $59 million to support accredited programs in advanced nursing education, including

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51 masters degree programs, post-masters ce rtificate programs and nurse midwifery certificate programs (Medicare Pa yment Advisory Commission, 2001). The National Health Service Corps Scholarship Program The National Health Service Corps was originally enacted by the Emergency Health Personnel Act of 1970 to respond to th e geographic maldistribution of primary health care professionals. The program, author ized under Title III of the Public Health Service Act, was comprised of scholarship and loan repayment programs that provided education and financial assist ance to students in the health professions. In return, the graduates served in HPSAs for a period of up to 4 years. By placing health professionals in medically underserved areas, the NHSC played a critical role in providing medical care to populations that would otherwise have had no access to health care services. The scholarship program was created in 1972 and the loan repayment program was initiated in 1987. The NHSC scholarship wa s created to provide financial support to health professions students in return for se rvice in designated areas. Similarly, the loan repayment program repaid both governmental and private loan obligations in exchange for service. In 1987, Congress also establis hed a State Loan Repayment program. Under this program, if a state es tablished a loan repayment program similar to the NHSC program, the Department could fund up to 75% of the total costs th rough a grant to the State (U.S. Congress, 2001). The NHSC Revitalization Amendments of 1990 extended the program for 10 more years and increased the use of nurse practitioners and phys ician assistants. In FY 2003 the NHSC made 1204 new loan repayment cont racts and 147 new scholarship awards; they also continued 78 scholarships from the previous year. FY 2004 saw $124 million in appropriations for NHSC loan repayment a nd scholarships. President Bushs FY 2005

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52 budget proposal called for a 21% increase to $159 million (Association of American Medical Colleges [AAMC], 2004). NHSC Scholarship Program Description. Congress mandated the NHSC to supply health care professionals with the nece ssary training and skil ls to deliver quality health care services to HPSA populations w ith the greatest need. The scholarship program provided the NHSC with graduates from qualified training programs who were capable of providing health care services to HPSAs throughout the United States. The program was not a general financ ial assistance program for students in health-related professions; rather it was a competitive Federal program, which awarded scholarships to students pursuing primary care health professions training. The scholarship provided payment of tuition, fees, and other reas onable costs as determined by the school. The scholars also received a monthly stipend of $1,065 (DHHS, 2003). Kirshstein, Berger, Benatar, and Rhodes argued that even th ough these types of programs were labeled as scholarship pr ograms; they could be more accurately described as Workforce Contingent Financia l Aid (WCFA) programs because recipients were required to repay the money if they fa iled to meet the workforce requirements. The authors described the criti cal elements of WCFA progr ams as (1) support to cover educational expenses either during or afte r schooling in exchange for (2) a workforce commitment as a condition for receiving assistance (American Institutes for Research, 2004). Scholarship programs, on the other hand, aw ard funds for the support of education with no requirement for repayment or workforce commitment.

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53 Student Eligibility In order to be eligible for NHSC scholarship awards, applicants were required to meet a number of requirements. According to DHHS, (2003) they must have been U.S. citizens or nationals and enrolled or accepted for enrollment as full-time students in an eligible, accredite d training program. Training programs must have resulted in the appropria te certification and/or licen sure as defined by the DHHS. While most scholarship recipients serv ed their commitments as salaried nonFederal employees of public or private en tities approved by the NHSC, there were occasional vacancies which required Federa l employment. Therefore applicants were required to be eligible to hold appointments as commissi oned officers in the Public Health Service (PHS) or as Fe deral civil servants. Additionally, applicants were required to be free of Federal judgment liens and deli nquent debts. They were also required to be free of other conflicting serv ice commitments (DHHS, 2003). The scholarship program selection process was very competitive. A number of factors were considered when selecting app licants. Potential scholars were required to demonstrate geographic flexibility and a strong interest in providing primary health care to the underserved populations nationally. First priority was given to previous scholarship recipients and medical student s who were recipients of th e Federal Schola rship Program for Students of Exceptional Financial Need (EFN). The second priority was given to applicants who demonstr ated characteristics that increased the probability they would continue to practice in HPSAs after they completed their service commitments. These characteri stics included experien ce with indigent or underserved communities, intent to participate in pre-professional clin ical experiences in

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54 rural or urban community-based health care facilities serving HPSA s, and strong primary care post-service career goals in HPSAs. A third priority was given to applican ts from disadvantaged backgrounds. These applicants demonstrated the HPSA retention characteristics and also were certified as having come from disadvant aged backgrounds (DHHS, 2003). Training Program Requirements. Nurse practitioner tr aining programs were required to be accredited by one of severa l listed accrediting bodies and must have awarded either a Masters de gree or a Post-Masters Cer tificate. Physician assistant training programs were required to be accredited by the Accreditation Review Commission on the Education of Physician Assi stants (ARC-PA). PA applicants were to have graduated from a 4-year baccalaurea te PA training program or a 2-year postbaccalaureate program with a Bachelors or Masters degree. Applicants graduating from a certificate program or Associate degree pr ogram were also required to demonstrate broad background knowledge of the medical envi ronment, practices and procedures. In lieu of this knowledge, they were required to provide proof of 3 or more years of responsive and progressive health care experien ce as a corpsman, medical technician or other health care worker. Program s must also have led to national certification as family nurse practitioners or as phys ician assistants (DHHS, 2003). Student Application Process. Applicants were required to submit applications along with supporting documents several months in advance. Application deadlines were usually in late March and award notifications complete by the end of September of the same year. The applicants submitted a signed contract and verification of acceptance or of good standing from an eligible training institution. Applicati ons of eligible individuals

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55 were scored numerically. If th e application fell within a competitive range, he or she was invited to a personal interview (DHHS, 2003). The NHSC scholarship program enjoyed a high level of interest among potential recipients. In a March 2000 testimony before a Senate Subcommittee on Public Health and Safety, Heinrich (USGAO, 2000) pointed out that the program had almost seven applicants for every available scholarship. Scholarship Benefi ts to Student. Scholarship benefit avai lability depended on funding appropriated by Congress for the current year. The scholarship award consisted of payments, in whole or in part, for tuition, an amount for all other reasonable expenses incurred by the student and a monthly stipe nd for the 12-month period beginning with the first month of each school year in which the applicant was a participant in the scholarship program. Scholarship support was limited to a maximum of 4 school years (NHSC, 2004a). Payments for Other Reasonable Costs (ORC) were based on cost estimates submitted by the scholars educational instit ution. These funds covered the costs of required books, clinical supplie s, lab expenses, instruments, two sets of uniforms, graduation fees, computer/PDA purchase or rental (if required of all students), and travel expenses for one clinical rotation. A taxable stipend of $1,065 was also provided for each month of scholarship support (DHHS, 2003). Scholars were also eligible to receive travel support fo r pre-employment interviews at eligible sites. Travel s upport was authorized up to a to tal of $1,100 in accordance with Federal Travel Regulations and NHSC travel policies.

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56 Upon placement, scholars were provided w ith support for relocation. This included reimbursement of travel expenses, shipme nt of household goods up to 18,000 pounds and storage of household goods for a maxi mum period of 90 days (NHSC, 2002). Repayment through service. In return for financial s upport, the scholars were required to fulfill their service commitment at HPSA locations in the United States and its territories. Students agreed to provide 1 year of service for each school year or partial school year of scholarship support receive d (DHHS, 2003). Scholars were required to engage in a full-time clinical practice, defi ned as a minimum of 40 hours per week for at least 45 weeks per year, not including oncall or teaching activities. The minimum service commitment was 2 years and the maximum was 4 years (NHSC, 2002). The scholars fulfilled the service commitment as non-federal employees, commissioned officers of the U.S. Public Health Service, or as civilian employees of the U.S. Government. About 92% of scholars serv ed as non-federal employees of public or private entities. Scholars provided full-time clin ical primary health car e services in highneed, high-priority HPSAs selected by th e Secretary of DHHS. The scholars were provided with a list of eligible sites approximately 4 months prior to the scheduled start of service. The Early Decision Alternative (EDA) option allowed scholars to compete for their choice of job vacancies on the list. R ecipients who failed to obtain placement in one of the approved practices by the deadlin e announced by the NHSC were involuntarily assigned to a practice based on the needs of the NHSC (DHHS, 2003). Several types of placement sites appeared on the HPSA list. These included NonFederal placements such as Private Practi ce Assignments (PPAs), which were public or private entities that operated a community-bas ed system of care, and Private Practice

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57 Options (PPOs), which were private practices that provided fee-for-s ervice or salaried positions at public, private non-profit, or for-p rofit sites. Federal placements included positions with the Indian Health Service (IHS), the Federal Bureau of Prisons (BOP), or the division of Immigration Health Servic es of the Immigration and Naturalization Service (INS). Governing Statutes allowed th e NHSC to provide a ratio of up to three potential practice positions for each schol ar up to a maximum of 500 positions (DHHS, 2003). While this may seem to be a generous number of potential employers from which each scholar may choose, the truth is that this same list of employers was shared by loan repayment recipients and anyone else that desires to work in a HPSA. Persistence, Employment and Default Default, the failure of a scholarship recipient to provide services as defined in the scholarship contract, resulted in severe penalties. If a recipient was found to be in breach of cont ract, the United States was entitled to recover damages equal to 3 times the scholarship award plus interest in accordance with the formula: A = 3 (t-s ) t Where A = the amount the U.S. is entitled to recover; is the sum of the amounts paid to or on behalf of the partic ipant and the interest on such amounts which would be payable if, at the time the amounts we re paid, they were loans bearing interest at the maximum legal prevailing rate as dete rmined by the Treasurer of the United States; t is the total number of months in the particip ants obligated period of service; and s is

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58 the number of months of the period of obligat ed service served by the participant. This was all to be paid with in 1 year of the date of default (DHHS, 2003). Challenges to this policy enjoyed little success. An analysis by Helms and Helms (1991) examined 110 cited judicial deci sions from 1950 to 1989 involving medical students and undergraduate medical educat ion. Disputes over financing medical education were involved in 54% of these cas es. These primarily arose from challenges to NHSC obligations and from attempts to reorganize or discharge debt under the Bankruptcy Code. The authors pointed to a need for informed counseling for medical students, particularly the default conseque nces of NHSC service obligations and of incurring loans under the Health Education Assistance Loan (HEAL) program as opposed to other loan sources. According to the Department of Health a nd Human Services, each year a number of NHSC scholars defaulted on their contractua l agreements. Between January 1st, 1999, and August 18th, 2004, approximately 120 physicians did not fulfill their obligation. Among nurse practitioners, 27 were in default. Of the approximately 50 nurse practitioner scholarships awarded per year, 4.5 scholars, or 9%, failed to fulfill their obligation. Physician assistants were less compliant. During the same 6-year period, 42 scholars defaulted. This was roughly seven per y ear or 14% of scholars (DHHS, 2004). Cullen, Hart, Whitcomb, and Rosenblat t (1997) examined the December 1991 American Medical Association (AMA) master fi le to determine the practice locations and specialties of 2903 NHSC physician scholars who graduated from medical school from 1975 to 1983. They found that 20% of the physicia ns assigned to rural areas were still located in the county of their initial assignment. An additio nal 20% were in some other

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59 rural location in 1991. The master file also in dicated that 20% of all students graduating from medical schools between 1975 and 1983 w ho were currently practicing in rural counties with small urbanized populations were initially NHSC scholars. A 2004 assessment report by the Office of Management and Budget (OMB) stated that in 2000, the long-term retention of up to 15 years of NHSC providers after the required service was 52% (U.S. Congress, 2004). But NHSC physicians may have demonstrated less dedication to service in HPSAs than non-NHSC physicians. A study by Pathman, Konrad, and Ricketts (1992) which contrasted the retention of NHSC and non-NHSC physicians serving in rural settings between 1981 and 1990, demonstrated that fewer NHSC physicians than non-NHSC physicians remained in their index practices (12% versus 39%), their index communities (29% versus 52%), or even in any rural county. Characteristics leading to long-term retention received much attention at the Federal level in recent years. NHSC Loan recipients may also have been more likely than scholars to continue practicing in an underserved co mmunity after completing thei r initial serv ice obligation. In testimony before the Senate Subcommittee on Public Health and Safety, Heinrich (USGAO, 2000) referred to an analysis of data for calendar years 1991 through 1993 indicating that 48% of lo an repayment recipients were sti ll at the same site 1 year after fulfilling their obligation compared to 27% of scholarship recipients. She suggested that this finding may be a result of the timing of the commitment by the recipient. Loan repayment recipients did not commit to service until after they have completed training. Therefore, they were more li kely to know what they wanted to do and where they wanted to practice at the time they made the commitment.

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60 While the findings of the Heinrich report merit consideration, these findings were based on anecdotal evidence drawn from a sm all sample of years. The NHSC did not have a comprehensive tracking system in place and did not consider th e quality of life or the specific medical needs at th e HPSAs. In an effort to direct scholarship recipients to the neediest sites, for instance, they were provided fewer choices of where they could fulfill their service obligation. Heinrich (USGAO, 2000) pointed to more anecdotal evidence suggesting no significant difference be tween service sites for scholars and loan repayers. Finally, the report ra ises an important point that the NHSC could make more efficient use of allocated funds. Few, if any, studies have examined the retention rates of NHSC non-physician clinicians and non-NHSC NPCs in these settin gs. Debt levels were generally lower and service obligation times were shorter for nonphysician clinicians. The mean obligation time for participants in this study was 2.2 y ears compared to approximately 4 years for physicians. Demographic differences such as ag e, marital status and family size may also have influenced NPCs differently than phys icians. Further, amounts of income foregone during the service period may have been sign ificantly different for physician assistants and nurse practitioners than for physicia ns, due to the shorter training period. There was an inherent expectation that the NHSC scholarship program was a good investment in that it provided a benefit to society. But, given the dearth of studies demonstrating any estimate of financial retu rn, perhaps it was the programs potential to create political capital that allowed it to continue from year to year. Accountability and Workforce Contingent Financial Aid Programs Perhaps it was time for the NHSC to revi sit the conceptual ideas and methodology involved in the creation, formulation, and distribution of schol arship funds. More

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61 important, the comparison of scholarship funds invested to health care needs met should have been more objectively considered. A 2004 report by the American Institutes for Research examined 161 workforce contingent financial aid programs in 43 states Three fourths of thes e programs were inschool programs that provided financial aid to students while they were enrolled in school in exchange for a future workfor ce commitment. The remainders were loan repayment programs. Participation data we re provided by 100 of the programs citing 23,000 individuals receiving s upport during the 2001-2002 academ ic year. Only 50 of the programs studied were able to provide data about how many students fulfilled their work commitment. The report questioned the effec tiveness of the programs and expressed the need for closer monitoring and evaluation (American Institutes for Research, 2004). Peter Schmidt (2004) described the report as providing little data to answer questions such as: 1. Did these programs help reduce labor shortages? 2. How well did the programs cover educational expenses? 3. How many participants drop out of the programs before fulfilling their work obligations? 4. Did these programs attract people who ot herwise might not have entered the occupations or specialties covered? Schmidt (2004) cited other concerns raised by the report. He contended that such programs may actually have caused harm because they provided psychological and political cover for college officials and St ate lawmakers seeking to raise tuition. He speculated that the programs made it easier to pretend that tuition increases didnt hurt

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62 real priorities like getting people into the teaching work force. Despite the costs, loan forgiveness and service-obligated programs may have been one of the only effective methods to provide medically underserved popula tions with adequate primary health care services. While numerous programs existed for funding the training of health care providers for service in underserved areas, the Federal government lacked an efficient and comprehensive system to measure outcomes a nd alleviate severe s hortages. Many of the problems stemmed from the process used to assign providers to service areas. Other problems were the result of faulty reporti ng requirements and unr eliable methods for identification and staffing of the area s with the most critical needs. In testimony before the Congressional S ubcommittee on Public Health and Safety, Janet Heinrich (USGAO, 2000) listed a number of ways that programs providing health care access to underserved populations c ould have been improved. Among her recommendations, she stated that more dollars should be shifted from NHSC scholarship programs to loan repayment programs. Among th e reasons for a change in priorities, she explains that (1) the loan repayment program s cost less, (2) loan repayment recipients were more likely to complete their service obligations, and (3) loan repayment recipients were more likely to continue practicing in underserved communiti es after completing their obligation. She also stressed a need for an improved sy stem for identifying the need for health care services in a community. Heinrich fu rther explained that HHS processes for determining HPSA designation were flawed in a number of ways. For example, nonphysician providers such as phys ician assistants and nurse pr actitioners as well as NHSC

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63 providers already practicing in the shortage area were not ro utinely counted. As a result, the system tended to overstate th e need for more providers. In a related issue, she asserted that th e current system for placement of providers was severely flawed. She cited a 1993 analysis which found that at least 22% of shortage areas that received NHSC providers received more providers than needed to increase their provider-to-population ratio to the point that their H PSA designation could have been removed. Meanwhile, 65% of shortage areas with Corps-approved vacancies remained unfilled. Of these vacancies, 143 lo cations remained unfilled for at least 3 years. Heinrich also recommended the reevaluati on of J-1 visa waivers for physicians who had just completed their graduate medical edu cation in the United States. In exchange for service in specified areas, the requirement fo r these new physicians to return to their home country could be waived. She cont ended that in 1999, the number of waiver physicians was large enough to meet the need s of over one third of HPSA designated sites nationwide. She concluded by describing the domestic placement effort as rudderless and without accountability (USGAO, 2000). Human Capital Theory Investment in human capital is as old as learning itself. Certainly, even the most primitive societies understood that teaching sk ills such as hunting, fishing and foraging would result in an increase in benefits to the group or tribe. Medieval blacksmiths invested time and effort to train apprentices with the expectation that the increased productivity would accrue benefits to the business. But it was not until the 20th century that human capital became a theoretical and empirical focus of the study of economics. In the 1930s Eugene Gorseline examined

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64 185 pairs of brothers who had differing leve ls of education within each pair. After controlling for intelligence, gender, re gion of the country, time, and family characteristics, he found that schooling had a significantly positive effect on income. He did, however, describe a sorting effect and asserted that abil ity plays a large part in the decision to further educate oneself (Langelett, 2002). In the early 1960s Theodore Schultz studi ed education as a method of building human capital. He examined the fundamentals of education both as an investment and as an institution (Schultz, 1963). Building on the work of Shultz Becker (1964) developed a broader theory of human capital As Becker pointed out, coun tries that enjoy consistent per capita GDP growth have simultaneously devoted substantial resources to the development of human capital th rough nationwide education. According to human capital theory, any type of education is an investment made by both the individual and the societ y or organization that devote d resources to it. Decisions on the amount of time, money and other resources to invest are based on expectations of private returns for the individual and soci al returns for the organizations and/or governments. Education, as an investment, has been shown to increase personal productivity and income. Langelett (2002) stated: Human capital is the know how of the work force that increases the productivity of each worker. The theory of human capital is that investments can be made in human beings as well as in physical cap ital, which yield a future stream of returns or dividends to the initial investment. Investment in human capital has been one of the ma jor sources of growth in modern economies during the past century. Th e process of investing in human capital normally takes a much longer tim e period than physical capital. Most often it takes approximately eighteen y ears of formal education. In addition, there are shorter investments in hum an capital over th e lifetime of the individual that can incl ude additional formal edu cation, on-the-job training, informal education, life experien ces, and learning by doing. ( p.1).

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65 As a social investment, education and tr aining have resulted in a more productive workforce and growth of the Gross Dome stic Product (GDP) (Psacharopolous, 1984). Critics argued, however, that education may simply function to screen out individuals with higher innate ab ility or characteristi cs that make employees more productive. Perhaps education serves as one of many m echanisms which sort individuals by their abilities and labels those abil ities with educational credenti als. Certainly, innate ability may directly impact ones productivity. Sim ilarly, ability can help a student maximize educational opportunity. Belfield (2000) desc ribed the alpha fact or as the so-called element of the returns to education which is a function of prior ability which may absorb between 40-80% of any earnings premium. In addition to screening and innate ability, one must consider factors such as deterior ation of education during the years following commencement, gains made from job experi ence and opportunities, or lack thereof, resulting from job performance. Belfield (2000) also descri bed the sheepskin effect as an increase in earnings solely as a result of a credential attaine d. For instance, a promotion may be awarded simply as a result of a persons academic degree attainment. The sheepskin effect implies that the awarding of a credential serves as a signal, and that non-credentialed years of education produce smaller return s. Belman and Heywood (1997) acknowledged the importance of the sheepskin effect, but demonstrated that as workers age and become more experienced the credential hol ds less significance. Perhaps the most powerful signal produced by the credential wa s when it became a screening tool for employers planning to hire young, new empl oyees with limited experience and few references.

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66 Grubb (1993) attempted to demonstrate eviden ce of the sheepskin effect in a paper that estimated the returns of postsecondary education using the National Longitudinal Survey of the Class of 1972 with earnings m easured at about age 32. He found that most of the individuals who enrolled in post secondary programs but failed to complete credentials had no higher earnings than high school graduates. Kane and Rouse (1995) questioned the empirical support for Grubbs findings. They contended that several variables were mis-measured and that, when corrected with reasonable alternatives, showed that those who entered but fail ed to earn credentials at community colleges did seem to earn more than similar high school graduates. The authors showed that both men and women wh o completed 1 year of community college without completing a degree earned appr oximately $900 to $1,000 (1985 dollars) more per year than high school graduates. While they conceded that the t-statistics were only marginally significant and did not provide overwhelming evidence of the value of a community college education wi thout credentials, they us ed the study to discount any evidence for sheepskin effects. For health care professionals, credentials are critically import ant. Without proper credentials at each level of professional deve lopment, health care practitioners would not be eligible for national certification examin ations, licensure and, ultimately, employment in their field. In fact, attainment of such credentials is clearly the most important yardstick by which the wort hiness and competence of health care professionals is measured. Psacharopolous (1979) distinguished a weak version from a strong version of the screening hypothesis. In the weak versi on, the employer pays higher starting wages to

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67 more educated workers because he lacks other information about their potential productivity. In the strong version, the empl oyer continues to pay higher wages to the more educated employee even though he has had an opportunity to evaluate their job performance. He discounted the strong vers ion as irrational, arguing that an employer will re-evaluate hiring decisions on an ongoi ng basis and make adjustments accordingly. Cohn and Geske (1990) pointed out anot her challenge to the human capital approach in the dual labor market hypothesis. Proponents of this hypothesis argue that the human capital approach is only va lid for certain segments of the labor force. In the dual theory the labor force is divided into a pr imary segment consisting of individuals hired into positions holding promise of economic and job mobility, and a second segment consisting of workers who were hired into pos itions where they were not likely to receive good ladder-type positions no matter how much theyve invested in training and education. The above concerns should not be viewed as arguments against the human capital model but as factors which may enhance or dilute the effects of an investment in education. Gains made from an investment in education could vary widely among the many disciplines of study. Prior work experi ence, motivation, and academic preparation could all play an important role in the acquisition of skills during the education process. Many forms of employment require the speci fic skills and funds of knowledge acquired from training and education. In the case of medical training, for instance, it would be unthinkable to assume that a person could be productive as a clinicia n without some form of investment in education.

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68 The Benefits of Education Education bestows a number of benefits on an individual. Cohn and Geske (1990) classified these benefits into consumpti on and investment components. Consumption benefits are those products or services which yield satisfaction or ut ility in a single period only. For instance, a certain sense of satisfa ction and pleasure may be derived simply from the activity of learning. In addition, ma ny college students gain certain social and entertainment benefits from campus life and w ould certainly prefer that to some of the alternatives. Investment benefits are those which are expected to yield satisfaction in future periods. By increasi ng ones productivity and, thus, ones capacity to earn higher wages in a free market, education not only co ntributes to the soci al product but could increase future consumption benefits to the individual. Education in troduces students to works of music, literature, and the arts a nd enables them to comprehend material they would otherwise not be expected to master. From this they are likely to derive greater utility from leisure activities. Benefits to the Individual. Education is, perhaps, th e single most important activity that a person can undertake to impr ove their economic and social success. In addition to increasing the capac ity to earn income, schooling and training increases ones productivity and, as such, increases ones chances, in a free mark et, to obtain higher wages and increase the contribution to th e social product (Cohn & Geske, 1990). Benefits of education may also be classifi ed as private and social. Edwin Dean (as cited in Langelett, 2002) pointed out eight ways in whic h education affects a persons economic well-being or income: First, and most directly, it increases ones human capital. The rest of the effects are indirect effects, but nevertheless they do affect ones income and well being. Second, there is an inverse relationship be tween the average level of education and

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69 fertility rates in a cross section of countri es. Third, education reduces search time in labor markets. Fourth, there is a correla tion between education and health of the work force. Fifth, there is a direct re lationship between the education level of children and their parents. More highly e ducated parents generally value education more and provide greater opportunities for their children to get a higher level of education. Sixth, there were consumption effects of education. More highly educated persons make more informed choices in their consumption patterns. Seventh, education has an effect on cr ime, social cohesion, and technology development. Regions with more educated citizens have more social cohesion and less crime, ceteris paribus. Finally, there are income dist ribution effects that affect average income. (p.11) Some benefits may belong to both domains. Social benefits include tax payments associated with the increased income stream and other external benefits that the individual cannot capture (Cohn & Geske, 1990). Benefits to Society. Schultz (as cited in Langelett 2002) identified a number of ways investments in education benefit not only the individual but the economy as a whole. First, education cha nges peoples images of themselves and of their society around them. It empowers them to question the status quo and build better lives for themselves and for those around them. Second, education empowers us to become better stewards of scarce resources while devel oping new ways to create alternate, and sometimes renewable, resources. Third, educa tion improves the health and increases life expectancies of individuals a nd societies as a whole. Four th, the business of education and the funds used to attend schools make a net contribution to ove rall economic growth. Fifth, research done at colleges and universit ies often leads to new products and more efficient ways of producing existing products. Gains in practical co mmercial research may also be enhanced as a result of research done at institutions of higher learning. Sixth, educational institutions nurture, discover, and cultivate talent. By raising the efficiency of the workforce and improving productivity, educa tion enhances physical capital and raises GDP. Educated workers are better able to choose fields that best utilize their interests,

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70 talents and ability. Seventh, education enhan ces peoples ability to adapt to change. The capability to adjust to changes in job requi rements and opportunities results in higher incomes and increased gross domestic product. Eighth, the education system is flexible enough to expand as demand increases for traini ng required to fill high paying jobs and to meet the countrys needs for people with specific skills and knowledge. Finally, education increases the labor force particip ation rate of women and minorities. In developing countries participation in educati on reduced fertility rates of women as well. Many professionals, such as health care providers, provi de a social benefit through activities that improve the h ealth and productivity of the community they serve. Some health care professionals use their educati on to produce professional literature for the benefit of their peers and the health ca re industry as a whole (Cohn & Geske, 1990). Fiscal Returns It was important to determine the relevance of the NHSC scholarship to rewards and compensation in order to gain an understand ing of the benefits to society and to the individual. A number of met hods may be used to estimate such benefits and returns. Fiscal Returns to the Individual. In The Economic Value of Higher Education Leslie and Brinkman (1988, p.39) immediat ely conceded that in conventional scientific and quantitative terms we were incapable of proving hi gher education to be worthy of any particular amount of public support. They go on to explain that the three major ways to estimate monetary yields of a college education were (1) earnings differential, (2) net present value (NPV) appro ach, and (3) internal rate of return (IRR). All have limitations that precl ude any accurate application to education policy decisions. Yet most estimates of return on educationa l investment seemed to imply that the margin of the value of higher education over that of most alterna tives was great enough

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71 to justify the expenditures. In 1980 the earni ngs differential for college graduates (men and women) compared to high school gra duates was 58% higher (Leslie & Brinkman, 1988). Cohn and Geske (1986) used 1976 census data to show that NPV earnings estimates at a 5% discount rate reflected a 62% greater benefit than cost for male college graduates and a 19% greater benefit for females. Leslie and Brinkman (1988) demonstrated four methods for grouping results of IRR estimates of college graduates. The mean estimates of the four methods suggested returns ranging from 11.8 to 13.4%. It is easy to conclude that by most estimates, investments in education seem to produce positive returns. But accurate measurem ents of the intrinsic variables that contribute to those conclusions remain elusive at best. Fiscal Returns to Society. In 1961 Theodore Schultz attributed additional schooling of the labor force for the about one-fifth of the rise in national income between 1929 and 1957 (Schultz, 1961). Over 2 decades la ter, Denison (1985) explained the 25% growth in the countrys pe r capita income between 1929 a nd 1982 by attributing it to a substantial growth in years of schooli ng observed during the same time period. Meanwhile, George Psacharopolous studied relationships between education and economic growth in a number of count ries around the globe. Using methodology developed by Schultz, he examined private a nd social returns using education as a proxy for human capital (Psacharopolous, 1979, 1984, 1985, 1987).

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72 More recently, Robert Barro (1999) found th at increased invest ments in education in the 1960s were at least par tially responsible for the subseq uent growth in per capita income. Individual and Societal Costs Cohn and Geske (1990) recognized the importa nce of earnings foregone by the student as an important element in total educational cost. These foregone earnings represented a loss to the student and the unrealized tax reve nues, a loss to societ y. Additionally, health care professionals, such as nur ses, through their work increas ed the productivity of some of their patients by get ting them back into the workfor ce sooner. These productivity gains were lost as the PA or NP student refrained from work to complete their training. Return Methodologies Honeyman et al. (1996) described three wa ys to estimate the monetary yield of a college education: (1) earnings differentials (2) the net present value approach, and (3) private rates of return. There was a conti nuing lack of consensus among some educators and economists over which of these was the mo st appropriate approach and exactly how returns were to be measured. Earnings Differential The earnings differential approach is perh aps the easiest to calculate and most rudimentary of the three. This measure describes how much mo re, on average, an individual earns than other individuals w ith less education. Th e earnings differential approach measures the calculated differen ce between the average sum of money that subjects with h years of schooling receive and the average sum received by those with only h -1 years of schooling using the formula:

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73 n DIFF = Wth Wth 1) t =0 where Wth is the average earnings, in year t for subjects with h years of schooling and n is the number of years worked (Becker, 1992). Becker (1992) also pointed out that while these calculations are easy to understand and simple to perform, they are unable to control for costs, disc ounting, or individual characteristics. He cautions, however, agai nst dismissing the method too quickly. He adds that other more sophisticated methods are highly sensitive to changes in costs or discount rates. He touts the simplicity of this approach as a virtue. Certainly, in more casual contexts and comparisons, this approach is adequate. Net Present Value Approach The net present value approach attempts to estimate the present value of an education by adjusting costs and benefits to reflect the changing value of a dollar over time. The result of such analyses is a be nefit/cost ratio. Becker (1992) describes the following formula for calculating the net presen t value for each year of schooling beyond h -1 years: n 0 NPV = (Wth-Wth-1) (1+d)-t (Cth +Wth -1) (1+d)-t t =1 t=-s where: Cth is a measure of cost, in year t for years of schooling h ; Wth is a measure of earnings, in year t for a person with h years of schooling; s is years of schooling considered, n is a measure of working life; and d is a rate of interest or discount.

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74 For instance, using net present va lue calculations, Cohn & Geske (1990) demonstrated that each dollar invested in 4 years of college yielde d, on average, $1.19 for women and $1.62 for men. Interestingly, the au thors also showed that postgraduate education dollars invested yielded $ 3.05 for women and only $1.00 for men when compared to the baccalaureate-prepared student. By discounting dollars to a common year, the NPV approach allows us to compare investments and returns made in different years. The approach also allows us to consider costs and foregone earnings. This method is very sensitive to changes in the discount rate (Becker, 1992). Because this requires the analyst to made calculations based on their own expectations about the future of the economy, a large am ount of variation can be evident from one analyst to the next. Internal Rate of Return By calculating the discount rate at which the NPV is equal to zero, one may arrive at the internal rate of return (IRR). This is perhaps, the most broadly used measure for estimating the value of an education. By projecting a lifetime stream of earnings and costs of attendance, the IRR relates total res ource costs of educati on to income benefits (Honeyman et al., 1996). The u tility of the IRR calculation co mes from the ability to use this measure as a means for comparison of di fferent investments. The IRR is, essentially, a reverse calculation of the NP V. But unlike the net present value calculation, the IRR is not heavily influenced by the discount rate selection. It is, howeve r, very sensitive to fluctuations in the cost of the investment (Becker, 1992). Economists and educators continue to deve lop new approaches to the problem. In the 1960s and 70s, for instance, researchers such as Eckaus (as cited in Bowen, 1977),

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75 Becker (as cited in Bowen, 1977), and Mincer (as cited in Bowen, 1977) considered the impact of ability, occupation and post-college influences on earnings. The importance of variables such as these depends upon the research questi on and conditions. Investment Returns Positive Production Several potential indicators of a positive return may be described as acceptable outcomes of the scholarship program: (1) se rvice in a medically underserved area, (2) improved community access to health care serv ices, (3) increased productivity of the community workforce through improved medical care, (4) involvement in community service activities and organiza tions, (5) attainment of con tinuing medical education, (6) personal advancement through specialized trai ning which required attainment of a specific degree or license provided by the sc holarship program, and (7) continuation in a postgraduate educational program that would not have otherwise been available without such a degree. Negative Production Several types of investment returns may not be considered to be positive. Some negative returns include: (1) failure to comp lete NP or PA school, and (2) failure to complete service agreement at a designated HPSA site, resulting in default. In these cases the NHSC recovers a penalty from the schol ar equal to three times the amount of unsatisfied debt from scholarship support. Wh ile this penalty may reimburse fiscal losses to the NHSC, it cannot make up for lost opportunity for other potential scholars. Other positive or negative investment return s also may have existed. In some cases, the fiscal return to society may not have been realized through increased tax revenues generated during the service commitment peri od. In these cases a scholars departure

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76 from a service site at the end of his or her commitment may still have constituted a negative return to society.

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77 CHAPTER 3 METHODOLOGY Research Design The purpose of this study was to examine the investment return to society and the individual for the National Health Service Corps (NHSC) scholarsh ip recipients from physician assistant (PA) and nur se practitioner (NP) programs in the United States who would have completed service obliga tions between the years 2003 and 2006. The problem will be addressed by answering the following questions: 1. Is the difference in the amount of Fede ral taxes generated between the preand post-training wages sufficient to e qual the cost of sc holarship awards? 2. How does the social debt ratio factor (t he ratio of total sc holarship costs to tax revenue generated during the obligat ed service period) change the time required to generate enough Federal ta xes sufficient to equal the cost of scholarship awards? 3. Are there differences in payback poten tial between nurse practitioners and physician assistants? 4. Are there differences in foregone ea rnings during training between nurse practitioners and phys ician assistants? 5. Do NHSC PA and NP scholars who comp lete training receive more or less income after graduation than before completion of their training program? To determine the societal investment retu rn, the amount of tota l scholarship funds received by each scholar was compared to the total present value of additional taxes paid over a 35-year period. To determine the indivi duals investment re turn, preand posttraining wages were compared. The estimates of additional tax revenues generated from students who received the NHSC scholarship and a theoretical group of those who did not receive PA or NP

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78 training were determined by comparing posttraining wage (scholarship group), and the expected salaries without th e training (no investment gr oup). These two distributions were used to determine an estimate of the di fference in the present value of taxes paid over a 35-year period. The 35-year career span was determined by adding the average PA student age of 28 years (AAPA, 2003b) to the training period (2 years) then subtracting the sum from the customary retirement age (65 years). The estimate of taxes paid each service year was compared to the total amount of NHSC funds awarded. The study used annualized preand post-training data from scholars who would have completed their service obligation in 2003, 2004, 2005, and 2006 and compared them to NHSC scholarship expenses reported by the Departme nt of Health and Hu man Services (DHHS, 2003, 2004), as well as data from the Bureau of Labor Statistics (Bureau of Labor Statistics [BLS], 2003), the American Acad emy of Physician Assistants (AAPA, 2003a, 2003b, 2003c, 2004), and the American Academy of Nurse Practitioners (AANP, 2004). Participants Physician assistant and nurse pract itioner NHSC scholars with valid mailing addresses on file at DHHS who would have completed their servi ce obligation between 2003 and 2006 participated in the study. These pa rticipants trained at accredited colleges and universities throughout the United Stat es and repaid their scholarships through service at Health Profession Shortage Ar eas (HPSAs) across the nation. While these colleges and universities may not have been representative of all PA and NP training sites, the data were adequate for estimati ng the costs of NHSC scholarships for students completing PA and NP training as well as estimating the needed payback levels.

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79 Participant Characteristics Scholars who would have completed service obligations between 2003 and 2006 provided the following data: 1. Pre-training salary 2. Post-training salary 3. Number of dependents clai med on last tax return 4. Pre-training vocation 5. Payback requirement in years Scholarship costs were estimated usi ng data provided by the DHHS (2004). For comparison, scholarship costs were calculated as the sum of tuition, stipend and awards for reasonable expenses. Payback Payback was defined as the reimbursement of monetary benefits to society and to the individual resulting from the scholarship investment. Student incomes before training as a PA or NP were considered incomes available through no further investment in education. To determine payback, wages for the no investment PA and NP groups were compared to the scholarship groups. For each subject the estimated annual income tax obligation was determined. Investment return was the difference in the aggregate net present values of all Federal income tax paid subtracted from the remaining scholarship debt. The required number of years of obligated service (service span) was defined for each subject. For the NHSC scholarship group the obligated service span was defined as the mean number of years required to sa tisfy the scholarship c ontract. The projected

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80 number of years to payoff was then calcula ted for both the scholarship and the noinvestment groups. Present Value The net present value returns the sum of any series of regular cash flows, discounted to a particular date using a singl e discount rate. In order to determine the present value of the wages and scholarship support, the NPV calculation was used to convert all values to 1997 dolla rs. This was calculated year-by-year using the applicable consumer price index reported by the Bureau of Labor Statistics fo r that year as the discount rate (BLS, 2005). By converting all values to 1997 dollars subjects can be treated as if all scholarships started on the same day. Social Debt Ratio Debt ratio is considered to be the debt payment over a given period of time divided by the gross income over the same time pe riod. The social debt ratio, then, is the monetary value of total scholar ship debt to be forgiven during a defined period divided by the additional tax revenues generated for the same period. Further, th e social debt ratio factor can be derived from the ratio of tota l scholarship costs to tax revenue generated during the obligated service period. To obtain th e social debt ratio factor the following formula was used: Y W Social Debt Ratio Factor = (Cb+Sb+Hb) / (Rb) i =1 i =1 where: Cb is a measure of tuition, in year b ; Sb is a measure of stipends paid, in year b ; Hb is a measure of other reasonable costs (books, fees, and supplies), in year b ; Rb is a

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81 measure of tax revenue generated, in year b ; Y is a measure of sc holarship years; and W is a measure of service years. All values were indexed to 1997. Qualifying Scholars for the Study There were a number of reasons why some participants were excluded from the study. Some disqualifying reasons included failure to respond to the survey, breach of contract, or deferment due to military service. For this study, any scholar who did not match to a HPSA and begin service was not included. Scholars without valid mailing addresses on file with DHHS were considered ineligib le and were also excluded. Data Collection Procedures Subject contact information, scholarship costs, service ob ligation and other reimbursement data were obtained through a series of Freedom of Information Act (FOIA) requests to the National Health Service Corps (DHHS, 2004). To obtain salary, service obligation, pre-training occupa tion and dependent information, a five question survey was deve loped. Following Institution Review Board (IRB) approval the surveys were mailed to 421 potential subjects. After a second mailing 107 envelopes were returned marked undeliv erable due to invalid address. Among the remaining 314 scholarship recipients, nurse practitioners returned 68 surveys. Physician assistants returned 63%, or 119, of the 187 su rveys. This yielded a combined response rate of 60%. Treatment of the Data The present value of wages earned by each individual scholar was used to compute two different distributions, one to represent expected earnings for no investment and one to represent scholarship investment of the study group. The no investment distribution projects wages ear ned in the absence of the sc holarship investment over the

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82 same time period as the scholarship group. Similarly, a second distribution was generated on wages earned after the scholar ship investment. Based on the annualized starting salaries, a taxes ge nerated figure was determined by projecting those salaries through the total service period. Salaries were increased by 3% annually to approximate customary raises in the industry. This was ba sed on the average changes in total inflationadjusted income from primary employers fo r PAs who stayed in primary care between the years 1997 and 2003 as reported in the Am erican Academy of Physician Assistants annual census reports (AAPA, 2003b, 2004) and Nurse Practitioners between the years 1997 and 2001 as reported by the Nurse Practiti oner Associates for Continuing Education annual census report (Pulcini, Vampola, & Ward, 2002). A special report by the ta x foundation (Moody & Hoffman, 2003) was used to estimate the average Federal tax burden on the American wage earner. The report estimated the national average effective Federa l tax rate for taxpayers in five income brackets earning between $0 and $292,913. Tax rates ranged from 4.1% to 23.7%. The effective tax rate was calculated for each year and for each par ticipant based on the estimated income for that year. Starting with the reported pre-training salaries, a si milar method was used to calculate foregone earnings of each of the scholars. Mean foregone earnings estimates were computed for PAs and NPs separately. Th e mean starting salary for all scholars was compared to the mean pre-training salary reported by the scholars.

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83 Payback Societal Payback The estimated monetary returns to soci ety were determined by comparing the 1997 value of the estimate of taxes paid over a 35-year period of the study group to the 1997 value of the scholarship expenses provide d during the training period. Scholarship expenses were calculated as the sum of tuition payments, stipends and reasonable expense allowances. Travel and relocation allowa nces were not considered as part of the scholarship cost since it is customary for employers to remunerate these costs. To determine the benefit to society, the differen tial between preand post-training taxes paid was computed for the study group. Using a report by Moody and Hoffman ( 2003), the annual taxes owed were then calculated based on the income for that year. Taxes were then totaled to determine an aggregate annual sum. As the projected income increased the tax rate was increased. This total was compared to a similar aggregate sum for pre-training earnings. The difference between both sets of tax revenues generated figur es is the estimated increase in societal benefits attributable to the increased wages earned by PA or NP training. For each service year the total of all taxe s paid by each of the scholars was then subtracted from the balance of scholarship funds awarded for PA or NP training. The result was the remaining debt owed by the scho lar. This procedure was used to calculate the payback potential for the average schol ar and for the scholars found to have the minimum and maximum so cial debt ratios. Individual Payback Individual payback was measured as increa sed individual earnings as a result of the scholars personal investment in their e ducation. This study examined the difference

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84 between annualized preand posttraining wages based on su rvey responses of recent scholarship recipients. Pre-trai ning wages were used to dete rmine foregone earnings that scholars would have otherwise received during the training pe riod. A 3% per annum increase was applied to both distributions. The difference between preand post-training wages projected over the service period minus foregone earnings is the potential payback to the individual scholar. Assumptions The payback to society and to the taxpaye r was based on a number of assumptions: (1) scholars began service in HPSAs immediately after grad uation, (2) salari es increased by 3% each service year and followed the same pattern as the U.S. gross national product (GNP), (3) students who did not receive schol arships did not have other higher education opportunities that increased th eir wages during the service period, and (4) scholars did not earn wages from a second job or have ot her sources of income during the service period. Comparisons Income Potential. Annual estimates of earnings for each year were compared between the scholarship group and the no investment group. This was projected over a 35-year period. A 3% annual raise was app lied to each group based on reported annual salaries. All comparisons were made using pre-tax dollars discounted to 1997 values using the consumer price index. Social Debt Ratio Factor. The total scholarship cost was divided by the aggregate tax revenue estimate for the obligated servic e period for each of the participants. This resulted in the social debt ratio factor whic h was then used to determine the scholars with the maximum and minimum debt ratios. A proj ection of tax revenue revealed that more

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85 than the 35-year expected career span was re quired for some of the scholars to pay back their debt. The projection was extended over a 49 year period in order to more accurately determine the times to pay back scholarship debt. Payback Potential. Mean annual estimates of va lue added tax revenues generated for each year were projected over a 35-year period for NPs and PAs. A 3% per annum increase was applied to each scholars sa lary and taxes were computed based on the appropriate income split point. Three compone nts of payback potential: (1) scholarship costs, (2) social debt ratio, and (3) starting salaries were compared for PAs and NPs using independent-samples t-tests. The relative ma gnitude of the difference between means for each component was estimated using an eta squared calculation. Foregone Earnings. Foregone earnings were estimated for each of the scholars based on their reported pre-training income a 3% per annum salary increase and tax payments based on the appropriate income split points. The mean foregone earnings estimates for PAs and NPs were then compared using an independent-samples t-test. The relative magnitude of the difference between means was estimated using a partial eta squared calculation. Effect of Training on Salaries Mean pre-training and post-training salaries and were computed separately for NPs and PAs. A split-plot analysis of variance was conducted to determine which variable (trainin g or discipline) had a greater influence on salaries and whether there was an interac tion effect. The relative magnitude of the difference between means for training, discip line and interaction effect was estimated using a partial eta squared calculation.

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86 Effect Size Calculations of eta squared were done to determine the relative magnitude of the differences between means. According to Taba chnick & Fidell (as cite d in Pallant, 2005) eta squared represents the propor tion of the variance in the in dependent variable that is explained by the dependent variable. The following formula was used to compute eta squared: Eta squared = ______ t2_________ t2 + (N1 +N2 2) where: t is the value derived from the t test; and N is a measure of the size of each of the samples in the study. Cohen (as cited in Pallant, 2005) desc ribed the following guidelines for the interpretation of strength of eta squared: .01 = small effect .06 = moderate effect .14 = large effect

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87 CHAPTER 4 RESULTS The purpose of this study was to examine the investment return to society and the individual for the National Health Service Corps (NHSC) scholarsh ip recipients from physician assistant (PA) and nur se practitioner (NP) programs in the United States who would have completed service obliga tions between the years 2003 and 2006. One hundred and eighty seven scholars chose to participate by completing a mail survey. Other data were obtained from the NHSC throu gh a series of Freedom of Information Act requests (DHHS, 2004), from the Bureau of Labor Statistics (BLS, 2003), and from census data provided by the American Academ y of Physician Assistants (AAPA, 2003a, 2003b, 2003c, 2004), and the American Academy of Nurse Practitioners (AANP, 2004). The study examined the following specific research questions: 1. Is the difference in the amount of Fede ral taxes generated between the preand post-training wages sufficient to equa l the cost of sc holarship awards? 2. How does the social debt ratio factor (the ratio of total schol arship costs to tax revenue generated during the obligated serv ice period) change the time required to generate enough Federal taxes sufficient to equal the cost of scholarship awards? 3. Are there differences in payback poten tial between nurse practitioners and physician assistants? 4. Are there differences in foregone ea rnings during training between nurse practitioners and phys ician assistants? 5. Do NHSC PA and NP scholars who complete training receive more or less income after graduation than before completion of their training program?

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88 Results of the Study Nurse practitioners and physician assistan ts who received the NHSC scholarship participated in this study. Specifically, 421 scholarship recipients who would have completed their service ob ligations between the year s 2003 and 2006 were initially selected as the study population. From th is population, 187 participants chose to participate through their response to a mail su rvey. In each mail survey the participants indicated the length of serv ice obligation, number of depe ndents claimed on last tax return, profession and income received in the year prior to training, and starting salary immediately after training, While detailed demographic informati on was not collected on each of the participants, there were a numbe r of characteristics that were normally considered when applicants are interviewed for the scholarship. Specifically, the scholars must demonstrate geographic mobility and a strong interest in providing health care to underserved populations. Experien ce with indigent or underser ved communities, intent to participate in pre-professiona l clinical experiences in ru ral or urban community-based health care facilities and strong primary car e post-service career goals in HPSAs were also important. The NHSC also gave prior ity to applicants from disadvantaged backgrounds (DHHS, 2003). The NHSC provided contact information for each of the scholars and data pertaining to the amount of sc holarship funds invested and years of service obligation. This information was obtained through the use of a series of Freedom of Information Act (FOIA) requests (DHHS, 2004). Following appr opriate Institutional Review Board (IRB) approval, short questionnaires (Appendices B and C) were mailed out to scholars on the mailing list provided by NHSC. The initia l mailing yielded 159 responses and 135

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89 envelopes marked undeliverable due to i nvalid addresses. A second mailing list was developed using the AAPA and AANP member directories. This yielded 28 more responses for a total of 187 out of 314 possible participants and a yield of 60%. The remaining 107 scholarship recipients were found to have invalid mailing addresses and were eliminated from the study population. The invalid addresses may have been due to participants who had changed service assi gnments, joined the military, deceased, or defaulted on their service ob ligation prior to the latest NHSC database update. Due to the differing lengths and dates of sc holarship support, years of service, and end obligation dates, all figures were inde xed to 1997, the first year of the study. This was done by sequentially indexing each figure ye ar-by-year using the net present value calculation with the pertinent year consumer price index as the discount rate. Table 4-1 shows the consumer price index and cumulative discount for each year of the study. Table 4-1. Consumer Price Index and Cumu lative Discount Rates (adopted from U.S. Department of Labor, 2005) 1998 1999 2000 2001 2002 2003 2004 2005 Consumer Price Index 1.56% 2.21% 3.36% 2.85% 1.58% 2.28% 2.66% 2.33% Cumulative Discount 98.47% 96.34% 93.21% 90.63% 89.22% 87.23% 84.97% 83.03% Tax revenues generated were estimated us ing a special report by the tax foundation (Moody & Hoffman, 2003) that reported the av erage Federal tax burden on the American wage earner. A 3% per annum raise was applied to each participants salary estimate. This was based on the average changes in total inflatio n-adjusted income from primary employers for PAs who stayed in primary care between the years 1997 and 2003 as reported in the American Academy of Physician Assistan ts annual census reports (AAPA, 2003b, 2004),

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90 and Nurse Practitioners between the y ears 1997 and 2001 as reported by the Nurse Practitioner Associates for Continuing Edu cation annual census report (Pulcini et al., 2002). As the next tax bracket was reached, the appropriate tax rate was applied for that year. Table 4-2 illustrates the income split poin ts for each of the tax brackets used in this calculation. Table 4-2. Federal Tax Brackets (ad opted from Moody & Hoffman, 2003) Income Split Point Average Tax Rate (Payment/AGI) Above $292,913 27.5% Above $127,904 23.7% Above $92,754 21.4% Above $56,085 18.1% Above $28,528 15.9% Below $28,528 4.1% Examination of the data showed that the payment for the average scholarship award, when indexed to 1997 dollars, wa s $56,625. The scholarship award included allowances for books, fees, lab supplies a nd a limited amount of travel. The median amount was $57,689. When the cost of the $1,065 monthly stipend is added, the mean scholarship award increases to $81,883. The maximum scholarship award was $164,678, provided to a physician assistant student ove r a 3-year period. The minimum award, $36,616, was awarded to another physician assist ant student for a 2-ye ar scholarship. The minimum number of years of scholarship support was 2 and the maximum was 4. Table 4-3 shows the distributio n of years of support by discipline. Among the participants in the study, 36% of NP students received more than 2 years of scholarship support compared to only 11% of PA students.

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91 Table 4-3. Years of Scholarship Support by Discipline Years 4 3 2 NPs 1 17 50 PAs 4 8 107 A total of over $15.3 million was used to provide 409 aggregate years of scholarship support to participants of th is study. The mean length of award for all participants was 2.2 years. Returns to Society The findings of this study i ndicate that the mean pre-tr aining annual salary for PA and NP scholars combined was $31,302. Nu rse practitioner scholars earned $35,502 during the year prior to star ting their training while physicia n assistant scholars earned $28,874. Research Question 1 Income Potential. Is the difference in the amount of Federal taxes generated between the preand post-training wa ges sufficient to equal the cost of scholarship awards? To answer this question, a scholarship group and a theoretical no investment group were used to compare the wages earned by participants in this study to those that would have been earned by similar PA and NP applicants had they not received any furthe r training. Wages were proj ected over a 35 year period for both of the groups. From this, the additional tax revenue generated was calculated. Figure 4-1 illustrates the projected cumulative Fede ral taxes generated for the scholarship group compared to the no investment group. While the no investment group continue d to generate tax revenue during the scholars 2-year training pe riod, the scholarship group di d not generate tax revenues until year 3. But by the end of the fifth year after matriculation, the scholarship group surpassed the no investment group in cumulative Federal taxes generated.

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92 Tax Revenues Generated0 50000 100000 150000 200000 250000 13579111315171921 Years1997 Dollars Scholarship No Investment Figure 4-1. Comparison of Cu mulative Taxes Generated It was also evident that none of th e scholars generated enough additional tax revenue during the obligated se rvice period to cover the cost s of their scholarship award. The calculation was extended to investigate how many additional years of service would be required to pay back the cost of the scholarship. The scholarship group generated enough total tax revenue to repay the average sc holarship debt in about 10 years. Another 9 years would have been required to repay th e debt with value added taxes. The no investment group needed 13 years to gene rate the same amount of tax revenue. Research Question 2 Social Debt Ratio. How does the social debt ratio factor (the ratio of total scholarship costs to tax revenue generate d during the obligated service period) change the time required to generate enough Federal taxes sufficient to equal the cost of scholarship awards? To answer this question, tax re venue projections were done based on the minimum and maximum social debt ratio factors. In this context social debt is the cumula tive sum of scholarship funds invested by society through programs such as the NHSC sc holarship. Payback is accomplished by the

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93 generation of additional tax reve nues as a result of the invest ment. The social debt ratio factor, then, is the ratio of th e total amount of scholarship f unds invested to the additional tax revenues generated during the obligated service period. Tabl e 4-4 compares the minimum and maximum social de bt ratios for PAs and NPs. Table 4-4 Minimum and Maximum Social Debt Ratio Factors by Profession Debt Ratio Factor Yrs Oblig Total Scholarship Debt Mean Aggregate Tax Payment Starting Wage Min 2.13 3 $63,164 $29,600 $54,168 NP Max 7.96 2 $129,580 $16,271 $49,920 Min 1.64 2 $46,789 $28,567 $77,417 PA Max 8.10 2 $129,468 $15,993 $49,067 Figure 4-2 suggests that the time require d to payback scholarship funds through additional tax revenues was directly related to the magnitude of social debt ratio factor of the scholar. The payback period ranged from 3 to 49 years. Scholarship Payback by Social Debt Ratio-$500,000 $0 $500,000 $1,000,000 $1,500,000 $2,000,000 051015202530354045 Service YearsValue Added Tax Revenues Generated Min Max Figure 4-2. Scholarship Payb ack by Social Debt Ratio Research Question 3 Payback Potential. Are there differences in payback potential between nurse practit ioners and physician assistants ? To answer this question, tax revenue projections were made based on the mean scholarship costs and starting

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94 salaries of the two groups. As Figure 4-3 illustrates, th e PA scholars were able to generate enough additional tax dollars to pay back the schola rship debt to society within 15 years. Nurse practitioner scholars needed al most 5 more years to pay back their debt. The rate of payback increased as part icipants reached higher tax brackets. Scholarship Payback by Profession-$100,000 -$80,000 -$60,000 -$40,000 -$20,000 $0 $20,000 $40,000 $60,000 $80,000 05101520 Service YearsAdditional Tax Dollars Generated PA NP Figure 4-3. Scholarship Payback by Profession Differences in payback potential may have resulted from differences in factors such as social debt ratio, scholarship costs, a nd starting salaries. Research Question 3 was further investigated by comparing these thr ee factors between the two groups. Table 4-5 illustrates a comparison of these three factors using independent-samples t-tests. Table 4-5 Independent-Samples t-test Analys is of Factors Affecting Payback Potential Factor Discipline Significant Difference Mean SD DF t P ETA 2 PA $78,623$18,251 Scholarship Costs NP Yes $87,587$27,469 101 2.405 .018 .003 PA 4.7171.42 Social Debt Ratio Factor NP No 4.7681.35 185 .236 .814 .00003 PA $49,586$7,871 Starting Salary NP No $49,743$7,338 185 .134 .893 .00005

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95 PAs were compared to NPs across the thre e variables: Scholarship Costs, Social Debt Ratio Factors, and Star ting Salaries. There was a stat istically significant difference in mean scholarship costs for PAs (M = 78623.25, SD = 18,251.22) compared to NPs [M = 87587.44, SD = 27469.31; t (101) = 2.405, p = .018]. But the magnitude of the differences in the means was small (eta s quared = .003). Chapter 3 includes a discussion of eta squared. There was no significant difference in soci al debt ratio factors between PAs (M = 4.717, SD = 1.42) compared to NPs [M = 4.768, SD = 1.35; t (185) = .236, p = .814]. The magnitude of the differences in the m eans was small (eta squared = .00003). Because payback is measured by additiona l tax revenues genera ted as a result of the scholarship-funded training, differenc es in payback potential between nurse practitioners and physician assist ants may also be influenced by this factor. There was no significant difference in starting sala ries between PAs (M = $49,586, SD = $7,871) compared to NPs [M = $49,743 SD = $7,338; t (185) = .134, p = .893]. The magnitude of the differences in the means was small (eta squared = .00005). This suggests that the mean payback poten tial was greater for the PA scholars in this study than for the NP scholars. This ma y not, however, hold true for scholars from year groups not incl uded in this study. Research Question 4 Foregone Earnings. Are there differences in foregone earnings during training between nurse practitioners and physic ian assistants? To answer this question the pre-training salaries for each of the groups were used to estimate the potential after-tax income lost by each part icipant during their training period. It was estimated that each participant would have received a 3% per annum increase in pay

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96 during this period. Estimated tax payments were subtracted based on income split points (Moody & Hoffman, 2003). The NHSC scholarship provides funding fo r tuition, books, supplies and a monthly stipend. This generous support decreases, but in most cases does not eliminate, all costs associated with schooling. Many of the particip ants earned some type of income prior to beginning their training. The costs of foregone earnings along with the costs of inflation caused many of the participants to make some fis cal sacrifices during their traini ng years. Some also realized a decrease in annual income after training. Th e mean amount of foregone earnings for all participants was $27,661. The maximum amount of foregone earnings was $66,830 and the minimum was $8,684. Figure 4-4 shows that the personal cost of training per annum for nurse practitioners was highest at $30,995. This was probably due to the fact that most NP applicants had an annual sala ry of over $35,000 as nurses. The physician assistant students, on the other hand, came fr om medical-technical fields and earned less than $30,000 prior to training.

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97 $30,995 $25,779 $0 $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 1997 DollarsMean Annual Foregone Earnings NP PA Figure 4-4. Foregone Income by Nurse Prac titioners and Physician Assistants An independent-samples t-test was conduc ted to compare the foregone earnings for nurse practitioners and physician assistan ts. There was a statistically significant difference in foregone earnings for nurse practitioners ( M = $30,995.21, SD = 12,095.82) compared to physician assistants [ M = $25,779.10, SD = $11,321.73, t (185) = 2.993, p = .004]. The magnitude of the differences in the means was small (eta squared = .046). Research Question 5 Effect of Training on Salary. Do NHSC PA and NP scholars who complete training receive more or less income after graduation than before completion of their training program? To answ er this question the pre-training and posttraining salaries for each of the two professions was compared using a split-plot analysis of variance. The mean pre-training annua l salary for PAs and NPs combined was $31,120. Figure 4-5 illustrates a comparison of pre-training and post-training wages among NPs and PAs. Nurse practitioner appl icants earned $35,502 during the year prior to starting their training wh ile physician assistant app licants earned $28,874. After

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98 training, the average nurs e practitioner salary in creased by $14,191 to $49,743. The average physician assistant post-training annual salary was $49,586, an increase of $20,681. The increase in income for PAs is at least $6,500 per year greater than that realized by NPs. $0 $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000 Pretrain $35,502$28,874 Post-train $49,743$49,586 NPPA Figure 4-5. Comparison of Pre-tr aining and Post-training Wages A split-plot analysis of variance was conducted to determine which variable (training or discipline) had a greater influe nce on salaries and whether there was an interaction effect. (Table 4-6). Table 4-6. Split-plot ANOVA of Traini ng and Discipline on Salaries Factor Significant DF F p Effect Size (partial eta2) Training Yes (1, 185) 194.18 <.0005 .51 Discipline Yes (1, 185) 7.21 .008 .038 Interaction* No (1, 185) 6.778 .010 .035 *Wilks Lambda = .49 Subjects were divided into two groups accord ing to their discipline (NPs and PAs). For both groups there was a sta tistically significant main effe ct for training [F (1, 185) = 194.18, p < .0005]; and the effect size was large (partial eta squared = .51). There was

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99 also a statistically significant main eff ect for discipline [F (1, 185) = 7.21, p = .008]; however, the effect size was small (partial eta squared = .038). This implies that training has a greater influence on salaries than discipline. The interaction effect [F ( 1, 185) = 6.778, p = .010) was not st atistically significant and the effect size (partial eta squared = .035) was small. Summary This chapter has presented a comparison of annual salaries and scholarship costs for nurse practitioner and physician assistant NHS C scholars. In this research, the survey was distributed to PA and NP recipients of the NHSC scholarship who would have completed their service oblig ation between the years 2003 and 2006. The responses were compared to data collected from the NHSC th rough Freedom of Information Act requests (DHHS, 2004), from the Bureau of Labor St atistics (BLS, 2003), and from census data provided by the American Academy of Physician Assistants (AAPA, 2003a, 2003b, 2003c, 2004), and the American Academy of Nurse Practitioners (AANP, 2004). Research Question 1. Is the difference in the amount of Federal taxes generated between the preand post-training wages suffi cient to equal the cost of scholarship awards? Additional Federal taxes generated after training were projected for each the scholarship and no investment groups to de termine the number of years required to repay society for the cost of scholarship support. The scholarship group generated enough total tax revenue to repay the average scholarsh ip debt in about 10 years. Another 9 years would have been required to repay the de bt with value added taxes. The no investment group needed 13 years to gene rate the same amount of tax revenue. Research Question 2. How does the social debt ratio factor (the ratio of total scholarship costs to tax revenue generated du ring the obligated service period) change the

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100 time required to generate enough Federal taxes su fficient to equal the cost of scholarship awards? A comparison of payback projections for scholars with minimum and maximum social debt ratio factors showed the time to repay the scholarship debt ranged from 3 to 49 years. Research Question 3. Are there differences in payback potential between nurse practitioners and physician assi stants? A comparison of scholar ship costs, debt ratio and starting salaries for NP and PA scholars s uggested significant diffe rences in payback potential between the two disciplines. Statisti cally significant differe nces in scholarship costs were found between NPs and PAs. Proj ection of additional tax revenues generated over a 35-year period compared to scholarship debt suggested 15 ye ars of service would be required for physician assistants to repay their debt while nurse practitioners require 20 years. Research Question 4 Are there differences in fo regone earnings during training between nurse practitioners and physician assistants? Comparisons of mean foregone earnings data suggest a stat istically significant difference between the two groups. Foregone earnings experienced by NPs were $5,216 greater than for PAs. This suggests that there may also be significant differences in the personal costs of education between the two groups. Research Question 5. Do NHSC PA and NP scholar s who complete training receive more or less income after graduati on than before completion of their training program? Comparison of annual salaries befo re and after training showed a significant return on the scholars personal investment in their education. Analysis of the effects of

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101 training and discipline (NP vs. PA) suggested that, while both had an effect on salaries, the effect of training was greater. Chapter 5 presents a discussion of the findings of this study. Also, recommendations are made for further research in the related fields of health care workforce analysis and education finance. The differences between Federal support for the NHSC scholarship and the benefits to soci ety and to the individual were examined in terms of conclusions that may be drawn from this study and implications for these conclusions to impact research, policy, a nd funding decisions for future programs.

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102 CHAPTER 5 CONCLUSIONS AND RECOMMENDATIONS FOR RESEARCH Introduction The purpose of this study was to examine the investment return to society and the individual for the National Health Service Corps (NHSC) scholarsh ip recipients from physician assistant (PA) and nur se practitioner (NP) programs in the United States who would have completed service obliga tions between the years 2003 and 2006. One hundred and eighty seven scholars chose to participate by completing a mail survey. Other data were obtained from the NHSC throu gh a series of Freedom of Information Act requests (DHHS, 2004), from the Bureau of Labor Statistics (BLS, 2003), and from census data provided by the American Academ y of Physician Assistants (AAPA, 2003a, 2003b, 2003c, 2004), and the American Academy of Nurse Practitioners (AANP, 2004). While a number of researchers have studied medically underserved populations (Hart, 2000; COGME, 1998; Dill et al., 1996) and characteristic s of clinicians who serve in Health Profession Shortage Areas (Gamm, Castillo, & Pittman, 2003; Fowkes, Gamel, Wilson & Garcia, 1994; Rabinowitz et al., 2001; Matherlee, 2003; Shi et al., 1991) there is a paucity of literature that examines th e fiscal returns to the programs aimed at provision of medical care to these populations. Perhaps the most objective and transparent an alysis of the overall effectiveness of the NHSC was done in 2004 by the Office of Management and Budget (U.S. Congress, 2004). In August 2001 the President announced an ambitious agenda for reforming the management of government and improving the performance and efficiency of a number

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103 of Federal programs. The agenda aimed to improve the governments performance and correct long-standing problems. One of the five elements of his agenda stressed the integration of budget decision making and perfor mance results. In order to effectively measure government programs a new instrument called the Program Assessment Rating Tool (PART) was introduced. The PART is an accountability tool that consists of approximately thirty questions, depending on the type of program being evaluated. It uses a four-point scale to indicate partial achievement of results. The instrument is divided into four sections: 1. Program purpose and design 2. Strategic planning 3. Program management 4. Program results and accountability The NHSC received an overall rating of Moderately Effective. The report describes the program as effective in increasi ng health care access and points to the fact that roughly half of program providers remain in service for a long period of time after the end of the Federal service contract. A lthough the program has shown some efficiency improvements by shifting resources, the OMB st ates that greater flexibility in allocation of funds between scholarships and loan s could further improve efficiency. The efficiency of workforce contingent financial aid programs similar to the NHSC scholarship have been studied (Schmidt 2004; USGAO, 2000) and found to be poorly administered and less than effective in ma ny cases. Measurement of fiscal returns to societys investment in such programs provi des a reasonable framework for evaluation of policy and funding decisions. This chapter expl ores the extent to which this studys findings contribute to a greater understanding of the relationship between NHSC

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104 scholarship support, costs of training and enhanced productivity of income and tax revenues generated by the scholar. Specifically the researcher addressed the following five questions: 1. Is the difference in the amount of Fede ral taxes generated between the preand post-training wages sufficient to e qual the cost of sc holarship awards? 2. How does the social debt ratio factor (t he ratio of total sc holarship costs to tax revenue generated during the obligat ed service period) change the time required to generate enough Federal ta xes sufficient to equal the cost of scholarship awards? 3. Are there differences in payback poten tial between nurse practitioners and physician assistants? 4. Are there differences in foregone ea rnings during training between nurse practitioners and phys ician assistants? 5. Do NHSC PA and NP scholars who comp lete training receive more or less income after graduation than before completion of their training program? Findings This study focused on Physician Assistan t and Nurse Practitioner scholarship recipients of the National Health Servi ce Corps scholarship w ho completed training between 2001 and 2004. One hundred and eighty-se ven scholars chose to participate by completing a mail survey regarding pre-trai ning and post-training a nnual salaries. Other fiscal data were obtained from the National Health Service Corps through a series of Freedom of Information Act requests (DHHS, 20 04), from the Bureau of Labor Statistics (BLS, 2003), and from census data provided by the American Academy of Physician Assistants (AAPA, 2003a, 2003b, 2003c, 2004), a nd the American Academy of Nurse Practitioners (AANP, 2004). Research Question 1. Is the difference in the amount of Federal taxes generated between the preand post-training wages suffi cient to equal the cost of scholarship

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105 awards? For the first research question, it was hypothesized th at the amount of Federal taxes generated between preand post-training wages would not be sufficient to equal the cost of the students scholarship award. The average projected income for the scholars was compared to the scholarship debt valu e indexed to 1997 dollars Additional Federal taxes generated after training were projected for each of the scholarship and no investment groups to determine the number of years required to repay society for the cost of scholarship support. The scholarshi p group generated enough total tax revenue to repay the average scholarship debt in about 10 years. Another 9 years would have been required to repay the debt with value adde d taxes. The no investment group needed 13 years to generate the sa me amount of tax revenue. This is important because the mean length of time required to repay the scholarship debt far exceeded the obligated service agreement period. The primary mission of the NHSC is not to educate health care providers but to place health care providers in shortage areas. Perhaps the money could be more efficiently spent on loan repayment programs and incentive bonuses to practicing clinicians. Societys fiscal investment in the scholars hip also varied grea tly from one scholar to the next. The minimum investment was $36,616 and the maximum investment was $164,678. The number of years of service obligati on also varied from 2 to 4 years. If there is any expectation that the NHSC will r eceive a return on its investment there must be a correlation between the amount of Fe deral dollars spent on education and the societal benefit received. Research Question 2. How does the social debt ratio factor (the ratio of total scholarship costs to tax revenue generated du ring the obligated service period) change the

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106 time required to generate enough Federal taxes su fficient to equal the cost of scholarship awards? For this research question it was hypot hesized that the magnitude of the social debt ratio would delay the repayment of the sc holarship. From the data a social debt ratio factor, or the ratio of total scholarship debt to aggregate tax revenue generated during the service obligation period, was calculated for ea ch of the scholars. Comparisons using the minimum and maximum social de bt ratio factors suggested that the times required to repay scholarship funds through the generation of tax revenue were dire ctly related to the amount of social debt carried by the scholar The payback periods ranged from 3 to 49 years. The primary reason for such large variations in social debt ratio factors was the difference in costs from one training program to the next. Total scholarship costs were not considered when the payback requirements were determined for each scholar. This is important because scholarship funding and service obligations were, in no way, contingent on the amount of funding re quired for tuition, books and supplies. Therefore a scholar who received 2 years of training at a very expensive institution incurred the same service ob ligation as a scholar who trai ned at a very inexpensive school. Measurable outcomes should be a refl ection of Federal dollars invested in a health care providers education. Research Question 3. Are there differences in payback potential between nurse practitioners and physician assist ants? Payback potential is a measure of how efficiently a subject can generate enough a dditional tax revenue to pay for the total cost of the scholarship. For this research question it was hypothesized that large differences in payback potential would not exist between NP and PA scholars.

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107 Projection of additional tax revenues gene rated compared to scholarship debt suggested 15 years of service would be requi red for physician assistants to repay their debt while nurse practitioners require 20 years. Differences in payback potential may have resulted from differen ces in social debt ratio factors, scholarship cost s, and starting salaries. The PA and NP scholars in the study were compared based on these three fact ors by using independent-samples t-tests. The analysis suggested a statistically si gnificant difference in mean scholarship costs for PAs. The magnitude of the differences in the means, however, was small. The difference in social debt ratio factors between PAs and NPs was not statistically significant. The magnitude of the differences in the means was small. The mean starting salaries for PAs and NPs are almost identical. But because payback is measured by additional tax revenues generated as a result of the scholarshipfunded training, differences in payback pot ential between nurse practitioners and physician assistants may also be influenced by this factor. The difference in starting salaries between PAs and NPs was not statistically significant. The magnitude of the differences in the means was small. This is important because it suggests that the payback potential for physician assistant scholars in this study was significantly greater than for nurse practitioner scholars due to the lower pretraining salaries reported by the physician assistants. If measurable outcomes are to reflect Federal dol lars invested in edu cation, variables such as scholarship costs and payb ack potential must be considered when determining payback requirements.

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108 Research Question 4. Are there differences in fo regone earnings during training between nurse practitioners and physician assistants? Diffe rences in foregone earnings directly impact the individual s cost of education. Monies that would have otherwise been earned would need to be, somehow, repl aced. In many cases this was probably done through reliance on savings or by borrowing additional funds. Without scholarship and stipend support, students would have had numerous other education-related expenses. In this study the assumption was made that the generous scholarship and stipend support was adequate to meet the costs of attending most institutions of higher learni ng. Expenses beyond these amounts were assumed to be the same for both PAs and NPs. The hypothesis for this question was that the nurse practitioner scholars were required to forego more income than the phys ician assistant scholar s during their training period. Most, if not all, nurse practitioner students were employed as nurses prior to matriculation. Physician assistant students on the other hand, came from a variety of backgrounds including lower wage medical-t echnical jobs. Most (76%) were students during the year prior to tr aining and only 8% were nurse s (AAPA, 2003a). The mean annual salary for NPs was $30,995 compared to $25,779 for PAs. An independent-samples t-test was conduc ted to compare the foregone earnings for nurse practitioners and physician assistan ts. There was a statistically significant difference in foregone earnings for nurse prac titioners compared to physician assistants. The magnitude of the differences in the means was small. While this suggests that nur se practitioners experienced more foregone earnings, the study did not examine factors such as spousal support, part-time or PRN income.

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109 According to Hooker, (2003) 96% of NPs were female. Among PAs only 54% are typically female (AAPA, 2003a). These gende r differences may have afforded nurse practitioners a greater potentia l to rely on spousal income to replace foregone earnings. This is important because it provides an estimate of individual costs of training. Scholarship stipends were provided for the pur pose of offsetting thes e individual costs. A better understanding of individua l costs associated with e ducation could affect funding decisions. Research Question 5. Do NHSC PA and NP sc holars who complete training receive more or less income after graduati on than before completion of their training program? Annual salary differences were used as a means of estimating the amount of additional tax revenue a schol ar could produce as a result of the scholarship-funded training. This analysis examines the effect of th is training on annual salaries as a way to measure increases in tax revenue generate d. The hypothesis for this question was that physician assistant scholars woul d experience a greater increase in mean annual salary as a result of training than the nurse prac titioner scholars. Even though mean starting salaries were very similar ($49,586 for PAs compared to $49,743 for NPs), the differences in mean pre-training salaries resu lts in a better return on the investment for PAs than for NPs. A split-plot analysis of variance was conducted to determine which variable (training or discipline) had a greater influe nce on salaries and whether there was an interaction effect. For both gr oups there was a statistically significant main effect for training and the effect size was large. There was also a statistically significant main effect

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110 for discipline. However, the effect size was small. The interaction effect was not statistically significant and the effect size was also small. This implies that training had a greater influence on salaries than discipline. This finding is important because it suggests that even though the return on investment was greater for PAs than for NPs, scholars from both disciplines benefited significantly as a result of the investment in education. Conclusion Previous studies on the investment retu rns of the NHSC scholarship have been nonexistent. This study focused on the ability of the NHSC physician assistant and nurse practitioner scholars to produce enough additiona l tax revenues to repay society for the costs of the scholarship. It was hypothesized that the amount of Federal taxes generated between preand post-training wages would not be sufficient to equal the cost of the students scholarship award during the service period. This study found that the aver age PA or NP scholar would have needed 10 years and 8 months of service to generate enough additional tax revenue to repay societys investment in the scholarship. One of the fact ors that influenced th e ability to repay the scholarship amount was the social debt ratio. Fu rther analysis revealed large variations in the years of service required to pay back the debt based on the magnitude of the social debt ratio factor. The number of years required to pay back the social debt ranged from 3 to 39 years. This research study suggested that si gnificant differences existed between physician assistants and nurse practitioner scholars ability to generate enough additional tax revenue to repay the scholarship costs. Th is was mainly due to significant differences

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111 in foregone earnings and in sala ry increases as a result of training. Mean annual starting salaries were not statistically di fferent between the two groups. One of the most important findings of th is study was that there was very little connection between measurable outcomes a nd the amount of monies invested in scholarships. Unlike the loan repayment program which defined an annual benefit ceiling, the NHSC scholarship program relied on the schools to determine the amount of tuition to be paid by the government. The findings of this study are consistent with findings of a 2004 analysis done by the Office of Management and Budget (U.S Congress, 2004) which emphasized the integration of budget decision-making and performance results. While the report described the NHSC scholarship program as effe ctive in increasing health care access, it called for improved efficiency through greater flexibility in allocat ion of funds between scholarships and loans. Indeed, the General Accounting Office ( 1995) concluded that loan repayment programs cost the government one-half to one -third less than the scholarship program. Further, the report stated that loan repaym ent program recipients were not only more likely to complete their service obligation, bu t they were more likely to stay beyond the end of their commitment. The implications of this study are also c onsistent with the Congressional testimony of Janet Heinrich (USGAO, 2000) who recomme nded that more dollars should be shifted from the NHSC scholarship programs to loan repayment programs. Recommendations for Future Research Few studies have been published that i nvestigate the return on investment for scholarship and workforce contingent fina ncial aid (WCFA) programs for health care

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112 professionals. Yet millions of Federal dollars were spent each year for scholarship programs that are politically appealing. Ther e are several recommendations for future research that stem from this study. Recommendation 1: As with most studies, re plication of the orig inal research is valuable. This will not only confirm or refute the original findings but may uncover reasons why the original rese arch should be questioned. Recommendation 2: Similar studies should be conducted to examine NHSC programs for physicians and nur ses. Analysis of these programs may uncover factors leading to policy change and more efficient placement of these clin icians in HPSAs. A 2004 OMB report found little evidence that the NHSC has incentives and procedures in place to improve the efficiency and cost-e ffectiveness of program execution (U.S. Congress, 2004). Recommendation 3: Comparisons of NHSC scholars and non-scholars should be done to investigate characteristics which increase the likelihood that a scholar will continue to serve in a HPSA beyond their initia l service obligation. Furt her, this type of analysis could help identify factors th at cause clinicians to leave HPSAs. Recommendation 4: Research should be done to explore the characteristics and efficiency of other types of scholarships, loan repayment and WCFA programs. Incentive programs for seasoned clinicians to stay in HPSAs may prove to be more efficient than continually pumping dollars into a pipeline of scholars. Further, studies should explore clinician attitudes and intere st regarding different types of WCFA program s and lengths of service commitment.

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113 Recommendation 5: The costs of training for NHSC health care providers as well as supplemental sources of income duri ng training should be explored. A 2004 OMB analysis found that the NHSC doe s not capture all direct and indirect costs borne by the agency and that the program does not have a procedure for splitting overhead costs between outputs, including scholar ships and loan repayment. The agency also fails to include informational displays in the budget that present the full costs of outputs (U.S. Congress, 2004). Thorough invest igation of all of the cost s of training will facilitate future rate of return analyses and resu lt in improved cost accounting practices. Summary The results of this study suggested that, from a purely fiscal standpoint, the NHSC scholarship program was an inefficient way to place clinicians into medically underserved areas. The overwhelming social debt ratio, high costs, meager payback potential and limited service period made this an investment that was nearly impossible to pay back during the service period. Although the limited cost-effectiv eness of the scholarship program compared to the loan repayment program has b een well understood, Jennifer Burke, acting director of the NHSC, emphasized that the scholarship program should not be eliminated altogether. She stated, Keeping both programs in our portfolio gives us a strong advantage. It allows us to react to what is going on in the fiel d (J. Burke, persona l communication, July 29, 2005). Indeed, the scholarship program has been a powerful tool to take promising students from medically underser ved areas, provide them with the resources to obtain an education they may not have ot herwise been able to get, an d return them to their home communities. While the mission of the NHSC did not necessarily include the provision of

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114 financial aid to target financial need, this particular strategy for scholarship award has been widely believed to result in better clin ician retention. But even with the employment of this strategy, scholar placement decisions did not always reflect the magnitude of societys investment. Analysis of the literature review for this study suggested that the obligated service period was, in no way, contingent on the amount of money spent on the scholarship. Unlike the loan repayment program which speci fied a benefit ceiling for each year of service, the scholarship service obligation is only contingent on the number of years of scholarship support. Scholars were required to serve at a site with a HPSA score above a specified threshold. The score was considered the programs primary indicator of medical need at a service site. But above the mini mum threshold for service sites, the HPSA score was not contingent upon the amount of money spent on the scholarship. One of the new key performance goals of the NHSC in 2004 was to increase the average HPSA score of areas receiving NHS C clinicians (U.S. Congress, 2004). This could be an important first st ep toward linking areas of great est need to Federal dollars spent. Finally, the results of this study suggested th at individual and soci al rates of return were, in general, higher for physician assist ant scholars than for nurse practitioners during the years studied. This was due to higher total scholarship costs and foregone earnings by the NP scholars. Mean annual starti ng salaries did not differ between the two groups.

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115 APPENDIX A ABBREVIATIONS AND ACRONYMS The following abbreviations and acr onyms were used in this study: AAPAAmerican Academy of Physician Assistants AANPAmerican Academy of Nurse Practitioners ARC-PAAccreditation Review Commission on the Education of Physician Assistants AHECArea Health Education Center ANCCAmerican Nurses Credentialing Center BLSBureau of Labor Statistics BOPFederal Bureau of Prisons COGMECouncil on Graduate Medical Education DHHS Department of Health and Human Services EDAEarly Decision Alternative FOIA Freedom of Information Act FQHC Federally Qualified Health Center GAOGeneral Accounting Office GMEGraduate Medical Education HEAL Health Education Assistance Loan HPSA Health Professional Shortage Area HRSAHealth Resources and Services Administration IHS Indian Health Services IMU Index of Medical Underservice

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116 INS Immigration and Naturalization Service IRB Institutional Review Board IRR Internal Rate of Return MGMA Medical Group Management Association MUA Medically Underserved Area NCBPN/NNational Certification Board of Pediatric Nurse Practitioners and Nurses NDSLNational Direct Student Loan NHSC National Health Service Corps NP Nurse Practitioner NPC Non-Physician Clinician NPV Net Present Value OMB Office of Management and Budget ORC Other reasonable costs PAPhysician Assistant PANCEPhysician Assistant National Certifying Examination PHSA Public Health Service Act PPA Private Practice Assignment SEOG Supplemental Educational Opportunity Grant WCFA Workforce Contingent Financial Aid

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117 APPENDIX B SURVEY MAILED TO NURSE PRACTITIONERS SURVEY Heres your chance to help a struggling gr aduate student and donate to charity at th e same time! Please complete the following short survey and return in the envelope provided. Your assistance is greatly appreciated. 1. What was your profession prior to NP training? ____________________________ 2. How many years are you required to serve to pay back your NHSC scholarship? ____ 2yrs ___3 yrs ___4 yrs 3. How many dependents (including yourself) did you claim on your last tax return? ____ 4. Please estimate your annual sa lary prior to NP training. ___ <$10,000 ___ $10,000$12,499 ___ $12,500$14,999 ___ $15,000$17,499 ___ $17,500$19,999 ___ $20,000$22,499 ___ $22,500$24,999 ___ $25,000$27,499 ___ $35,000$37,499 ___ $37,500$39,999 ___ $40,000$42,499 ___ $42,500$44,999 ___ $45,000$47,499 ___ $47,500$49,999 ___ $50,000$52,499 ___ $52,500$54,999 ___ $55,000$57,499 ___ $57,500$59,999 ___ $60,000$62,499 ___ $62,500$64,999 ___ $65,000$67,499 ___ $67,500$69,999 ___ $70,000$72,499 ___ $72,500$74,999 ___ $75,000$77,499 ___ $77,500$79,999 ___ $80,000$82,499 ___ $82,500$84,999 ___ $85,000$87,499 ___ $87,500$89,999 ___ $90,000$92,499 ___ $92,500$94,999 ___ $95,000$97,499 ___ $97,500$99,999 ___ $100,000$102,499 ___ $102,500$104,999 ___ $105,000$107,499 ___ $107,500$109,999 ___>$109,999 5. Please estimate your starting annual sala ry at your scholarship repayment site ___ <$40,000 ___ $40,000$42,499 ___ $42,500$44,999 ___ $45,000$47,499 ___ $47,500$49,999 ___ $50,000$52,499 ___ $52,500$54,999 ___ $55,000$57,499 ___ $57,500$59,999 ___ $60,000$62,499 ___ $62,500$64,999 ___ $65,000$67,499 ___ $67,500$69,999 ___ $70,000$72,499 ___ $72,500$74,999 ___ $75,000$77,499 ___ $77,500$79,999 ___ $80,000$82,499 ___ $82,500$84,999 ___ $85,000$87,499 ___ $87,500$89,999 ___ $90,000$92,499 ___ $92,500$94,999 ___ $95,000$97,499 ___ $97,500$99,999 ___ $100,000$102,499 ___ $102,500$104,999 ___ $105,000$107,499 ___ $107,500$109,999 ___>$109,999 Thank you for your help! For each completed survey received I will make a $1.00 donati on to one of the charities listed below. Please choose one. _____ American Cancer Society _____ Childrens Miracle Network _____ St. Judes Childrens Hospital

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118 APPENDIX C SURVEY MAILED TO PHYSICIAN ASSISTANTS SURVEY Heres your chance to help a struggling gr aduate student and donate to charity at th e same time! Please complete the following short survey and return in the envelope provided. Your assistance is greatly appreciated. 1. What was your profession prior to PA training? ____________________________ 2. How many years are you required to serve to pay back your NHSC scholarship? ____ 2yrs ___3 yrs ___4 yrs 3. How many dependents (including yourself) did you claim on your last tax return? ____ 4. Please estimate your annual sa lary prior to PA training. ___ <$10,000 ___ $10,000$12,499 ___ $12,500$14,999 ___ $15,000$17,499 ___ $17,500$19,999 ___ $20,000$22,499 ___ $22,500$24,999 ___ $25,000$27,499 ___ $35,000$37,499 ___ $37,500$39,999 ___ $40,000$42,499 ___ $42,500$44,999 ___ $45,000$47,499 ___ $47,500$49,999 ___ $50,000$52,499 ___ $52,500$54,999 ___ $55,000$57,499 ___ $57,500$59,999 ___ $60,000$62,499 ___ $62,500$64,999 ___ $65,000$67,499 ___ $67,500$69,999 ___ $70,000$72,499 ___ $72,500$74,999 ___ $75,000$77,499 ___ $77,500$79,999 ___ $80,000$82,499 ___ $82,500$84,999 ___ $85,000$87,499 ___ $87,500$89,999 ___ $90,000$92,499 ___ $92,500$94,999 ___ $95,000$97,499 ___ $97,500$99,999 ___ $100,000$102,499 ___ $102,500$104,999 ___ $105,000$107,499 ___ $107,500$109,999 ___>$109,999 5. Please estimate your starting annual sala ry at your scholarship repayment site ___ <$40,000 ___ $40,000$42,499 ___ $42,500$44,999 ___ $45,000$47,499 ___ $47,500$49,999 ___ $50,000$52,499 ___ $52,500$54,999 ___ $55,000$57,499 ___ $57,500$59,999 ___ $60,000$62,499 ___ $62,500$64,999 ___ $65,000$67,499 ___ $67,500$69,999 ___ $70,000$72,499 ___ $72,500$74,999 ___ $75,000$77,499 ___ $77,500$79,999 ___ $80,000$82,499 ___ $82,500$84,999 ___ $85,000$87,499 ___ $87,500$89,999 ___ $90,000$92,499 ___ $92,500$94,999 ___ $95,000$97,499 ___ $97,500$99,999 ___ $100,000$102,499 ___ $102,500$104,999 ___ $105,000$107,499 ___ $107,500$109,999 ___>$109,999 Thank you for your help! For each completed survey received I will make a $1.00 donati on to one of the charities listed below. Please choose one. _____ American Cancer Society _____ Childrens Miracle Network _____ St. Judes Childrens Hospital

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126 Tumolo, J. & Rollet, J. (2004). Gliding higher NP salaries ascend at a steady pace [Electronic version]. Advance for Nurse Practitioners, Retrieved March 2, 2005, from http://bhpr.hrsa.gov/healthworkforce/reports/scope/scope1-2.htm U.S. Bureau of Labor Statistics. (BLS) (2003). Occupational employment and wage estimates, 2002 Retrieved July 14, 2004, from http://stats.bls.gov/ oes/2002/oes291071.htm U.S. Bureau of Labor Statistics. (BLS) (2005). Consumer Price Indexes. Retrieved March 11, 2005, from http://www.bls.gov/cpi/home.htm#data U. S. Congress. (2001). Health care safety net amendments of 2001 (Report No. 107-83). Washington, DC: Congressional Committ ee on Health, Education, Labor and Pensions. U. S. Congress, Office of Management and Budget. (2004). Performance and management assessments Washington, DC: U. S. G overnment Printing Office. Retrieved August 3, 2005, from http://www.whitehouse.gov/omb/budget/fy2004/pma.html U. S. Congress, Office of Technology Assessment. (1986). Nurse practitioners, physician assistants, and certified nu rse midwives: A policy analysis (OTA-HCS-37). Washington, DC: U.S. Government Printing Office. U. S. Congress, Office of Technology Assessment. (1990). Health care in rural America (OTA-H-434). Washington, DC: U.S. Government Printing Office. U.S. Department of Education. (2001). Federal support for educa tion: Fiscal years 1980 to 2001. (NCES 2002-129). Retrieved September 12, 2004, from http://nces.ed.gov/pubs2002/2002129.pdf U.S. Department of Education. (2004). Federal support for educa tion: Fiscal years 1980 to 2003. (NCES 2004-026). Retrieved September 12, 2004, from http://nces.ed.gov/pubs2004/2004026.pdf U.S. Department of Labor. (2004). Occupational outlook handbook, 2004-05 edition, physician assistants Retrieved February 22, 2005, from http://www.bls.gov/oco/ocos081.htm U. S. General Accounting Office. (1995). National Health Service Corps: Opportunities to stretch scarce dollars and im prove provider placement. (Publication no. GAO/DEHS-96-28) Retrie ved April 14, 2004, from http://www.archive.gao.gov/papr2pdf/155725.pdf U. S. General Accounting Office. (2000). Health care access: Programs for underserved populations could be improved. (GAO/T-HEHS-00-81) Retrieved April 24, 2004, from http://www.gao.gov/archive/2000/he00081t.pdf

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128 BIOGRAPHICAL SKETCH Bob Philpot grew up in Keystone Heights, Florida. At age 18 he enlisted in the U.S. Army as a medic. He served on a helicopte r ambulance in Hawaii. After his enlistment, Bob received a Bachelor of Sc ience degree in interdisciplin ary sciences from Belhaven College in Jackson, Mississippi. During this time he worked nights as an Operating Room Technician. Upon graduation he re turned to active duty, completed Officer Candidate School and was assigned to a tour of duty at Ft. Richardson, Alaska. In 1990, he served as an instructor at the U.S. Ar my Aviation Center and School. He went on to command the 260th Field Artillery Detachment at Ft Rucker, Alabama. During this time he earned a Master of Science degree in counseling psychology from Troy State University at Dothan. Bob left active duty in 1992 to attend Emory University Physician Assistant Program; he was subsequently awarded a Natio nal Health Service Co rps scholarship. In 1994 he earned a Master of Medical Science de gree. Bob was assigned to a rural health clinic in Parrish, Florida, to pay back his scholarship obligation. Du ring his service period he practiced pediatrics, internal medicine and family practice. After 4 years with Manatee County Rural Health Services Inc., Bob was presented with another opportunity to teach. He began as a Clinical Assist ant Professor at the University of Florida College of Medicine Physician Assistant Program. In 2003 Bobs doctoral studies were interrupted when he wa s called to service with the Florida Army

PAGE 141

129 National Guard in support of Operation Iraqi Freedom. Upon his return he resumed his studies and began a fellowship program in medical education.


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FINANCIAL RETURNS TO SOCIETY BY NATIONAL HEALTH SERVICE CORPS
SCHOLARS WHO RECEIVE TRAINING AS PHYSICIAN ASSISTANTS AND
NURSE PRACTITIONERS













By

ROBERT J. PHILPOT JR.


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA


2005

































Copyright 2005

by

Robert J. Philpot Jr.

































This document is dedicated to the clinicians of the National Health Service Corps. Your
unwavering dedication to the medically underserved certainly makes you
"America's Health Care Heroes."















ACKNOWLEDGMENTS

Thanks to the patience and generosity of colleagues, committee members, friends

and family, working on this dissertation has been a rich and rewarding experience. I am

grateful to those who lent critical support, patiently listened while I discussed the current

state of my research, and simply gave me space and time to work.

Dr. David Honeyman, the chair of my committee, was extremely helpful in all of

my graduate studies. I am grateful for his willingness to discuss various aspects of my

project even by cell phone while vacationing in another state. His demeanor and sage

advice put things into reasonable perspective when everything felt chaotic.

Dr. Parker Small took the time to help me focus on the dissertation from the very

beginning. Always eager to hear about my progress, it was not unusual for him to call

from Cape Cod to discuss my findings. I am grateful that he, too, was willing to give up

some of his vacation time to critique my work.

Dr. Larry Tyree always seemed to have time to listen to my concerns and

aspirations. From family and work responsibilities to my involvement in Operation Iraqi

Freedom, he was always available for advice and encouragement.

Dr. Dale Campbell was an early influence during my graduate studies. He opened

my eyes to the diverse and exciting world of the community college and to the world of

educational leadership and administration. His careful analysis and critique of my

performance helped me to better understand what it takes to excel in higher education.









My colleagues and friends at the University of Florida Physician Assistant Program

were all directly or indirectly responsible for my success. Wayne Bottom, Dean and

Director of the Program, patiently gave me opportunities and time to develop as a faculty

member and doctoral student. Joan Crisman was willing to proofread my manuscript and

provide excellent feedback. The rest of the faculty and staff were always willing to listen

and provide feedback as I repeatedly discussed my research. For all of this I am, indeed,

grateful.

I thank the soldiers from Camp Blanding who volunteered in their off-duty time to

help me address, stamp and stuff envelopes. Similarly I am grateful to the graduate

students who volunteered to file and tally the survey results as they came in. This was

important but tedious work that has not gone unnoticed.

Last, but certainly not least, I am grateful to my family. Their support and

encouragement were instrumental in getting me through some of the more challenging

phases of this research. Cynthia is my foundation. She never complained when I needed

time and space to work. Despite the enormous challenges she faced in her battle with

cancer she continually sacrificed her own time to cover my responsibilities at home.

Finally, I appreciate my two sons, Rob and Austin, for enduring my absence during all of

my graduate studies and for sharing the wonders and challenges of adolescence.
















TABLE OF CONTENTS

page

A C K N O W L E D G M E N T S ................................................................................................. iv

LIST OF TABLES ............................. ......... .... ......................... ix

LIST OF FIGURES ................................. ...... ... ................. .x

ABSTRACT ........ .............. ............. ...... .......... .......... xi

CHAPTER

1 IN TR OD U CTION ............................................... .. ......................... ..

D definition of T erm s ................. ................................ ........ ........ .......... .......
State ent of the Problem ............................................................................. ........ 4
C conceptual F ram ew ork .................... .. ............................... ........................... ......6
Financing Physician Assistant and Nurse Practitioner Training .................................9
M measuring Production ................................................... ........ ............... 12
Fiscal R returns to the Individual.................................... ..................................... 12
F iscal R returns to Society ........................................................................ ... ... 14
Justification for the Study ................................... ................................... ............... 15
Lim stations ............................................................... .... ..... ........ 19

2 REVIEW OF THE LITERATURE ........................................ ........................ 21

The Maldistribution of Health Care Providers in the United States...........................21
The Use of Non-Physician Clinicians...................................................... ...............28
N urse P ractitioners........ .................................................................... .. ....... .. ..... .. 29
P ro file ................................................................ 3 0
T ra in in g ............................................................................................................... 3 0
Scope of P practice .............. ....................................................................... 3 1
S a la rie s .......................................................................................................... 3 2
W ork S ettin g s ............................................................... 32
P ro d u c tiv ity ................................................................................................... 3 2
Physician A ssistants............................................. 33
Profile ................................................. 34
Physician Assistant Training .............. .............................................. 34
S a la rie s ................................................................ 3 5
Scope of Practice .............. ............................................................ .................36









W ork S ettin g s ...............................................................3 6
Productivity ........................................37
Assistance to Health Profession Shortage Areas.................................................38
M ed care .................................................................................................. 3 8
M medicaid ............. .................... .......................... .... .... ........ 38
Foundations and Trusts................................................ ............................ 39
Public H health Service A ct ............................................................................40
A rea H health Education Centers ........................................ ....................... 41
National Health Service Corps ............................. ....... ............. 42
Economic Incentives for Community Health Centers.......................................43
Federal Support for Higher Education...................................................................44
Recent Federal Involvement in Higher Education ...........................................47
Federal Support for M medical Education ................................... .................49
Federal Funding of PA and NP Training ..............................................50
The National Health Service Corps Scholarship Program...........................51
Accountability and Workforce Contingent Financial Aid Programs ..................60
H um an C capital T theory ....................................................................... ..................63
The B benefits of Education ........................................................ ............... 68
F fiscal R returns .......................................................................70
Individual and Societal C osts ........................................ ......................... 72
R return M ethodologies ........................................................................ .................. 72
E earnings D ifferential .................................................... ........ ....... ............72
N et Present V alue A approach ........................................ .......................... 73
Internal R ate of R eturn ......................................................... ............... 74
Investm ent R returns ................................................. ....... .. ........ .... 75
P positive P reduction .......... ........................................................... ... .... ..... .. 75
N negative Production .................. .............................. .. .. .. .. ........ .... 75

3 M E T H O D O L O G Y ............................................................................ ................... 77

R e se arch D e sig n ................................................................................................... 7 7
P articip an ts ...............................................................7 8
Participant Characteristics ............................................................................. 79
P ay b ack ...................................... ............................................... 7 9
P resent V alu e ................................................................................... 80
Social D ebt R atio ....................................................... ... .. ....... .... 80
Qualifying Scholars for the Study ............................................ ............... 81
D ata Collection Procedures ....................................................... .... ........... 81
Treatm ent of the D ata .................................................... .. .. ................. 81
P a y b a c k ................................................................................................................. 8 3
Societal Payback................................................. 83
Individual Payback .................. .......................... .... .... ... ........ .... 83
A ssum option s .......................................................................84
C om prisons .................................................................... .......... 84
E ffe ct S iz e ...................................................................... 8 6









4 R E S U L T S ............................................................................................................. 8 7

R results of the Study .................. ........................................... .............. 88
R etu rn s to S o city ................................................................................................. 9 1
R research Q question 1 ................................................. .. ........ .......... .. .. 9 1
R research Q question 2 ......................................................................... 92
R research Q question 3 ............................ ...................... .... ....... .... ..... ...... 93
R research Q question 4 ......................................................................... 95
R research Q question 5 .................................................. .............................. 97
Sum m ary ................................................................................................... ..... 99

5 CONCLUSIONS AND RECOMMENDATIONS FOR RESEARCH ................ 102

In tro du ctio n ...................................................02..........
F findings .............................................................................104
R research Q question 1 .......................... .. .............. ................ ............. .. 104
Research Question 2. ............ ......................... .......... 105
Research Question 3 ...... ............. ................. .. ........................106
Research Question 4. ............ ......................... .......... 108
R research Q question 5 ...... ........ ...... ... . .. ........... ... .................... 109
C on clu sion .. .......... .. ...... .. ...................................................................... 110
Recommendations for Future Research................... ................. ............... 111
Summary ......... ........ ..................................... 113

APPENDIX

A ABBREVIATIONS AND ACRONYMS.....................................................115

B SURVEY MAILED TO NURSE PRACTITIONERS ............................................117

C SURVEY MAILED TO PHYSICIAN ASSISTANTS ............ ...............118

L IST O F R E F E R E N C E S ......... .. ............... ................. .............................................. 119

B IO G R A PH ICA L SK ETCH ......... ................. ...................................... .....................128
















LIST OF TABLES


Table p

4-1. Consumer Price Index and Cumulative Discount Rates..........................................89

4-2. Federal Tax B rackets ....................................................... ........ .......90

4-3. Years of Scholarship Support by Discipline.............................................................91

4-4 Minimum and Maximum Social Debt Ratio Factors by Profession..........................93

4-5 Independent-Samples t-test Analysis of Factors Affecting Payback Potential ..........94

4-6. Split-plot ANOVA of Training and Discipline on Salaries................... ............98
















LIST OF FIGURES


Figure page

1-1. A Comparison of Sources Used by Physician Assistants and Nurse Practitioners
to Pay for Training ......................... ......... .... ..... ...... ........... ..10

4-1. Comparison of Cumulative Taxes Generated............................... ...............92

4-2. Scholarship Payback by Social Debt Ratio ..................................... .................93

4-3. Scholarship Payback by Profession............................................... .................... 94

4-4. Foregone Income by Nurse Practitioners and Physician Assistants...........................97

4-5. Comparison of Pre-training and Post-training Wages ..........................................98















Abstract of Dissertation Presented to the Graduate School of the University of Florida in
Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy

FINANCIAL RETURNS TO SOCIETY BY NATIONAL HEALTH SERVICE CORPS
SCHOLARS WHO RECEIVE TRAINING AS PHYSICIAN ASSISTANTS AND
NURSE PRACTITIONERS

By

Robert J. Philpot Jr.

December 2005

Chairman: David Honeyman
Major Department: Educational Leadership, Policy and Foundations

The purpose of this study was to examine the investment return to society and to

the individual for the National Health Service Corps (NHSC) scholarship recipients from

physician assistant (PA) and nurse practitioner (NP) programs in the United States who

would have completed service obligations between the years 2003 and 2006. The study

examined the difference in the amount of Federal taxes generated between the pre- and

post-training wages compared to the cost of students' scholarship awards and differences

in payback potential between NPs and PAs. Differences in foregone earnings, scholarship

debt and starting salaries are also compared.

This study examined 187 NHSC scholars who would have completed their service

obligation between the years 2003 and 2006 in numerous Health Professional Shortage

Areas (HPSAs) across the nation. The initial data were collected by surveys sent to 314

scholarship recipients as well as existing census data from the Bureau of Labor Statistics,









the American Academy of Physician Assistants and the American Academy of Nurse

Practitioners.

The major findings of this study were that (a) scholars repaid society's investment

within 19 years after graduation, (b) PA scholars generated more tax revenue than NP

scholars, (c) time to repayment was highly dependent upon scholarship debt, (d) nurse

practitioner students were required to forego an average of $5,216.00 more potential

income than physician assistant students during training. While most scholars received

more income as a result of training, the PA scholars in this study appeared to enjoy larger

increases in salary than NP scholars. Finally, the service period for NHSC scholars was,

in no way, contingent on the amount of money invested in their scholarship.














CHAPTER 1
INTRODUCTION

The Federal government, through various programs, provides more primary care

clinicians to Health Profession Shortage Areas (HPSAs) in the United States than any

other source (see Appendix A for a complete list of abbreviations). During fiscal year

2003 the Department of Health and Human Services (DHHS) received 20 % ($25.4

billion) of the Federal on-budget funds for education. From these funds the DHHS

provided $46 million to the National Health Service Corps (NHSC) (U.S. Department of

Education, 2004). These funds were used to support numerous programs with the aim of

providing doctors, dentists, physician assistants, nurse practitioners, and other trained

health care professionals to care for the medically underserved populations of America.

In 1970 the Emergency Health Personnel Act, which authorized assignment of

Federal personnel to shortage areas, served as a mandate for the creation of the National

Health Service Corps. Two years later a group of clinicians consisting of 14 physicians,

four dentists and two nurses were assigned to underserved communities. Later that year

Congress passed amendments to the Emergency Health Personnel Act that authorized

scholarships to aspiring health professionals in return for service in communities with

critical health needs. Throughout the rest of the decade and into the 1980s, the NHSC

identified HPSAs, created loan repayment programs, and expanded scholarship offerings

to a wider range of health care providers. With this expansion came large increases in

funding (National Health Service Corps [NHSC], 2004b).









The NHSC scholarship program was mandated by Congress to supply health care

professionals trained in those disciplines and specialties most needed to deliver quality

primary health care services to HPSAs with the greatest need. Scholarship funds were

made available to health professional students training for a period of up to 4 years. In

return, the clinicians served in an identified area of need 1 year for each year of

scholarship support. The expectation of the DHHS was that many of these clinicians

would continue to serve in these underserved areas after their service obligation had been

fulfilled. Repeated training and recruitment of clinicians for these HPSAs required

additional funding.

One of the missions of the DHHS was to staff HPSAs with well trained clinicians.

This was done through a number of Federal initiatives to include the NHSC Scholarship

program. There was an inherent expectation that the scholarship was a good investment.

However, no research was found in the literature that provides an estimate of financial

return from the government's scholarship investment. There was also an expectation that

certain societal benefits accrue from the availability of primary health care services in an

underserved community. Yet few, if any, studies attempted to measure the societal

dividends of the NHSC scholarship program.

This study provides an evaluation of the NHSC Scholarship for PAs and NPs with

the hope that more efficient ways of making health care services available to America's

medically underserved populations could be developed. Careful analysis of the

relationship between funds invested and outcomes achieved can lead to funding and

policy decisions that result in a more efficient use of tax dollars.









Definition of Terms


The following definitions were used in this study:

Federally Qualified Health Center (FQHC) is a type of provider defined by the
Medicare and Medicaid statutes. FQHCs include all organizations receiving
grants under section 330 of the Public Health Service Act.

Health Professional Shortage Area (HPSA) is a geographic area, population group,
public or nonprofit private medical facility or other facility determined by the
Secretary of Department of Health and Human Services to have a shortage of
primary health care professionals.

Index of Medical Underservice (IMU) is a score used to measure the adequacy of
medical service in a service area. The index involves four variables-ratio of
primary medical care physicians per 1,000 population, infant mortality rate,
percentage of the population with incomes below the poverty level, and
percentage of the population age 65 or over. The value of each of these variables
for the service area is converted to a weighted value, according to established
criteria. The four values are summed to obtain the area's IMU score.

Medically Underserved Area (MUA) is a geographic area or population designated by
the Department of Health and Human Services based on an index of variables
known as the index of medical underservice (IMU).

Non-physician clinician (NPC) is a licensed medical provider, usually a physician
assistant, nurse practitioner or nurse midwife who practices within limited
guidelines or under the supervision of a physician.

Payback Potential refers to the potential to repay debt through the generation of
additional tax revenues.

Persistence refers to a scholar's continued service in a designated health profession
service area beyond the terms of the service obligation.

Scholar refers to a recipient, past or present, of the NHSC Scholarship.

Scholarship is an award usually based on academic achievement, community
involvement, or similar factors. Most scholarships do not require repayment. For
the purposes of this study, the term scholarship specifically refers to the NHSC
Scholarship.

Service Obligation refers to a defined period of service, normally 2 to 4 years in a
medically underserved area to satisfy the terms of the NHSC Scholarship contract.
Generally, each year of scholarship support incurs 1 year of service obligation.









Social Debt Ratio is the monetary value of scholarship debt to be forgiven during a
defined period divided by the income for the same period.

Social Debt Ratio Factor was derived from the ratio of total scholarship costs to tax
revenue generated during the obligated service period.

Workforce Contingent Financial Aid (WCFA) programs provide financial aid to
students by assisting individuals with their educational expenses in exchange for
service in either specified fields or specified locations.

Statement of the Problem

The problems addressed in this research involved the fiscal return to society and to

the individual from the Federal government's investment in NHSC scholarships for

physician assistants and nurse practitioners. The research was specific to PAs and NPs

who received NHSC scholarships to complete training programs across the United States

between 2001 and 2004. The study examined the following specific research questions:

1. Is the difference in the amount of Federal taxes generated between the pre-
and post-training wages sufficient to equal the cost of scholarship awards?

2. How does the social debt ratio factor (the ratio of total scholarship costs to
tax revenue generated during the obligated service period) change the time
required to generate enough Federal taxes sufficient to equal the cost of
scholarship awards?

3. Are there differences in payback potential between nurse practitioners and
physician assistants?

4. Are there differences in foregone earnings during training between nurse
practitioners and physician assistants?

5. Do NHSC PA and NP scholars who complete training receive more or less
income after graduation than before completion of their training program?

Few, if any, studies have been published that pertain to the NHSC Scholarship

program for physician assistants and nurse practitioners or to the benefits derived by

society and by the individual students.









A 1995 U.S. General Accounting Office (GAO) report analyzed cost, retention, and

other data in an effort to (1) compare costs and benefits of the NHSC scholarship and

loan repayment programs and (2) determine whether NHSC has distributed available

providers to as many eligible areas as possible. Investigators concluded that the NHSC

loan repayment program costs the government one half to one third less than the

scholarship program. The report also found that recipients of loan repayment funds were

not only more likely to complete their obligated service commitment than scholarship

recipients, but they were more likely to stay beyond the end of their commitment.

The scholarship program was intended to allow the NHSC to place health care

providers in the areas with the most critical health care needs because the scholars

enjoyed less freedom of choice when selecting service sites. The GAO report, however,

suggested that there was generally little difference in the priority of sites where

scholarship and loan repayment recipients practice.

Additionally, the report pointed out that the NHSC does a poor job of allocation of

provider resources based upon the health care service needs of eligible shortage areas.

The awkward measurement criterion used often resulted in excess placements in some

shortage areas and limited the government's ability to meet needs in others. The study did

not, however, compare the scholarship program's fiscal costs and benefits to the

government or to the individual (United States General Accounting Office [USGAO],

1995).

For participants of this study, the NHSC scholarship paid for the entire cost of their

training plus a taxable stipend of $1,065 per month for living expenses. Other non-

taxable funds were provided to cover the costs of books, supplies and travel. The tuition









payments were also non-taxable. The scholarship was awarded for a minimum of 2 years

and a maximum of 4.

Scholarships were funded based on the expenses the scholars were expected to

incur at the educational institution they attended. In other words, as long as the school

met the NHSC criteria as an eligible, accredited school, the amount of scholarship dollars

invested was not an issue. For instance, a student at an expensive, private college could

have received substantially more in scholarship dollars than a student at a more

economical public university. Placement of graduates, on the other hand, was done with

no regard to the amount of Federal funds invested in the scholar's training. For example,

a scholar who received only $30,000 in financial support could have been placed at a site

with a higher HPSA score, indicating a critical need for health care services. Conversely,

a scholar who received $90,000 in financial support could have been placed in a site with

a much lower HPSA score. This could have resulted in a much lower potential for social

return on the investment. As it was administered, this system failed to provide any

incentive for scholars to seek out sites with higher need. In other words, the NHSC

lacked scholarship, loan repayment or other incentive programs that definitively tied the

amount and type of award to the health care needs of the communities they served. More

important, there was no system in place to evaluate the returns, fiscal or otherwise, of

society's investment in this scholarship program.

Conceptual Framework

The fiscal return on investments made in NHSC scholarship support for NPs and

PAs provides a reasonable outcome measure by which data can be evaluated. This study

examined the relationship between NHSC scholarship support and enhanced productivity

of income and additional tax revenues generated by the scholar.









Hansen (1963) defined production value as the generation of wages from

employment pursuits. Wage-earning activity results in generation of tax revenue. Positive

production value then becomes the increase in wage-earning capacity due to increased

employment opportunity as a result of education or training. As an individual's earnings

increase it is reasonable to expect that the contribution to the tax base will increase

accordingly. Within this framework, Dunn (1996) used increases in tax revenues

generated to demonstrate financial returns by Pell Grant recipients receiving Associate in

Science degrees. Using an approach similar to the one used in this study, he found that

grant recipients repaid society for the cost of the grant within 2 years.

Because positive productivity is a direct result of human capital development, the

concept of human capital continues to dominate the economics of education and the

analysis of labor markets. "The concept of human capital refers to the fact that human

beings invest in themselves, by means of education, training, or other activities, which

raises their future income by increasing their lifetime earnings" (Woodhall, 1987 p.21).

Investment, or the expenditure of time or money on assets which could produce income

in the future, must be distinguished from consumption, which requires the expenditure of

time or money on goods and services to satisfy an immediate need but creates no

potential for increased future benefit. Using this framework, one could draw a working

analogy between investment in physical capital and investment in human capital.

While much has been written about measuring the fiscal returns of education, there

was a paucity of literature examining workforce-contingent scholarship programs and the

monetary returns to the individual or to society. The NHSC, for example, spent a large

number of Federal dollars to recruit, train, and place clinicians in medically underserved









areas. But there were no effective measures being taken to track long-range production

and fiscal returns.

Patterns of funding should be established with at least some awareness and

consideration of expected returns to the scholarship investment. If the returns are not

measured, it is impossible to compare the program to other reasonable alternatives.

As the largest provider of scholarships for clinicians destined to work in HPSAs,

the NHSC has faced numerous large changes in funding over the years. In the 1970s the

corps enjoyed funding of over $140 million to provide scholarships for about 1700

clinicians annually. Following Senate hearings which revealed a default rate of nearly

20%, funding was cut to less than $10 million (USGAO, 1995) and scholarships dropped

to about 50 per year (Shapiro, 1994). Although it was likely that the program had

successfully delivered medical care to underserved areas, the results were difficult to

demonstrate. Without measuring such outcomes the corps will continue to be challenged

to demonstrate the positive impact the scholarship program has on America's medically

underserved communities.

It was important to study the NHSC scholarship program for NPs and PAs because

the outcomes of these endeavors were an often-overlooked investment return. The scope

of practice for NPCs was expanding and the roles and responsibilities for members of

these two fairly new professions were becoming better established. Medical care

organizations were responding by finding new ways to maximize their productivity. Yet

many studies that examined physician workforce issues still did not consider the

contribution of NPs and PAs.









Financing Physician Assistant and Nurse Practitioner Training

Reasons to become a physician assistant (PA) or nurse practitioner (NP) vary. Two

common reasons were for higher pay and forjob satisfaction. While non-physician

clinician (NPC) salaries were much lower than those of physicians, the shorter training

period resulted in much less foregone income. Job satisfaction may have stemmed from

the increased ability to help others or from greater autonomy in decision making. Job

satisfaction also came from the flexibility to easily move from one work setting to

another. Students had the expectation that these benefits would offset the sacrifices

endured during their training years.

The American Academy of Physician Assistants (AAPA) 2003 census of new

enrollees in PA programs found that among the respondents most planned to pay for their

education with loans. Other popular sources of funding included personal savings, family

support, grants and scholarships. Service-obligated sources were the smallest source of

funds. While the amount of expected debt from PA training ranged greatly, from $5,000

(10th percentile) to $80,000 (90th percentile), the mean amount of expected debt was

$41,032 (American Academy of Physician Assistants [AAPA], 2004).

The costs for nurse practitioner training were similar. Yet NPs seemed less likely to

rely on loans. In a 2000 national sample survey Spratley, Johnson, Sochalski, Fritz, and

Spencer (2000), asked registered nurses to indicate all of the sources of money used to

fund their education. Among the respondents, 72% of nurses pursuing master's degrees

relied on personal and/or family resources to cover the costs of tuition and fees. About

41% of the respondents received tuition reimbursement from their employers and a little

more than 20% relied on loans. Only about 20% were supported by traineeships,










scholarships or grants such as the NHSC Scholarship. Figure 1.1 is an illustration of

sources used by PAs and NPs to fund their training.


How PAs and NPs Pay for School

80

60

Percent of 40
Respondents
m NPs
20

0
Loans Personal Employer Grants &
Sources Tuition Scholarships

Figure 1-1. A Comparison of Sources Used by Physician Assistants and Nurse
Practitioners to Pay for Training. Adopted from Spratley et al. (2000) and
AAPA (2003c)

Some Federal programs sought to provide incentives for students in the health care

professions with the aim of influencing them to provide medical care to underserved

populations. One such program was the NHSC Scholarship Program. This program

provided fiscal support to students in the form of tuition, stipends and allowances for

travel, books, supplies and other reasonable expenses. In exchange, graduates agreed to

repay the debt through 1 year of service in an identified service area for each year of

financial support.

Upon initial examination, workforce-contingent investments, such as the NHSC

scholarship program, may appear to be noble and responsible endeavors in that they

required the recipients to "repay" society for the investment made in their education. But

the terms of the contract sent the implied message that 1 year of service was equal in

value to 1 year of scholarship support.









Outcomes were, at best, haphazardly measured using criteria that were cumbersome

and subject to misinterpretation. This resulted in duplication of placement in some areas

and shortages in others. Similarly, HPSA criteria could have been so narrowly interpreted

that a doctor's office could have qualified as a HPSA while the hospital across the street

from the office did not.

Yet, few have ever questioned the fiscal responsibility and effectiveness of such

government programs. Perhaps because of the immense size and complexity of these

programs and the departments that administered them, or perhaps due to the beneficent

nature of a program designed to educate health care providers and serve the great need

for medical care in certain populations, the public unequivocally accepted the idea that

these programs met society's needs in an efficient and responsible manner.

The NHSC scholarship program was chosen for this study because its mission of

providing care to underserved populations was important enough to warrant the

expenditure of significant amounts of social capital and resources. But just as important

was the need to identify, measure, and understand variables and outcomes that could

facilitate efficient investment and allocation of Federal funds.

At the end of the day the question must be asked whether the large amount of time

and money invested in the NHSC scholarship program produced a future offset through

positive production. There should have been a point where it became necessary to

properly account for these funds and measure returns on the government's human capital

investments. Programs not meeting some minimum return threshold could have been

deemed too expensive to become justifiable. DHHS funds were designated specifically

for the purpose of decreasing morbidity and mortality in the neediest Americans. With









this designation comes the emotional baggage that makes funding cuts seem cruel and

maleficent. But excessive waste of such funds due to program mismanagement and lack

of accountability would be equally irresponsible.

Measuring Production

It was important to determine the relevance of the NHSC scholarship to rewards

and compensation in order to gain an understanding of the benefits to society and to the

individual. A number of methods could be used to estimate such benefits and returns.

Fiscal Returns to the Individual

Honeyman, Wattenbarger, and Westbrook (1996) described three ways to estimate

the monetary yield of a college education:

1. earnings differentials

2. the net present value approach

3. private rates of return

The earnings differential approach is perhaps the easiest to calculate and most

rudimentary of the three. This measure describes how much more, on average, an

individual earns than other individuals with less education. The earnings differential has a

number of limitations. Most important, it fails to measure preexisting differences as well

as costs of education.

The net present value approach attempts to estimate the present value of an

education by adjusting costs and benefits to reflect the changing value of a dollar over

time. The result of such analyses is a benefit/cost ratio. For example Cohn and Geske

(1990) demonstrated that each dollar invested in 4 years of college yielded, on average,

$1.19 for women and $1.62 for men. Interestingly, postgraduate education dollars









invested yielded $3.05 for women and only $1.00 for men when compared to the

baccalaureate-prepared student.

Estimation of the present value of a college education using the net present value

approach is, however, problematic in that the discount rate (the interest rate used to

determine the present value of future cash flows) selected by the analyst is based on the

analyst's own view of the economic future. The net present value calculation is heavily

influenced by the discount rate (Leslie & Brinkman, 1988).

The most broadly used measure for estimating the value of an education is the

internal rate of return (IRR). The IRR is the discount rate at which the net present value

calculation equals zero. By projecting a lifetime stream of earnings and costs of

attendance, the IRR relates total resource costs of education to income benefits

(Honeyman et al., 1996). Unlike the net present value calculation, the IRR is not heavily

influenced by the discount rate selection.

To calculate the IRR the analyst must first examine earnings and costs corrected to

current dollars. The discount rate that would set the earnings value equal to the cost value

is the IRR. In other words, the IRR can be considered to be the relative increment of

earnings associated with a given increment of education (Mincer, 1974).

The IRR is useful in that it is easy to compare to other potential yields. Leslie and

Brinkman (1988) pointed out, however, that IRR calculations were extremely sensitive to

the cost, as opposed to the benefits, of education. They also explained that because IRR

calculations compound costs forward and discount earnings backward the calculation

tells us more about the costs of education than the benefits.









They suggested that IRRs were an inappropriate base for making decisions about

public support for higher education because the calculation is more of a reflection of how

generous society has been in supporting higher education. Simply stated, society can

easily influence IRRs by funding a larger share of the cost of education.

This study evaluated the usefulness of continuing support for the NHSC

scholarship program. Specifically, the study examined the levels of income and years

required to return the value of the scholarship to society. The study also allowed for

generalizations to be made about the time required for payback of taxpayer funds based

on starting salaries and average number of years a scholar stays in a HPSA.

Fiscal Returns to Society

Investments in education may also result in growth of the national income.

Specifically, medical education may raise labor quality by imparting greater discipline,

better health, and heightened mobility. The practice of medicine may not only influence

the amount of available labor in the community, but also could impact the labor

participation rate. Preventive medicine also has the potential to decrease costs associated

with disease and therefore boost the rates of savings and investment among patients.

Non-physician clinicians underwent shorter training periods than physicians and

the graduates were able to enter the workforce earlier. In the case ofNPs and PAs, value

added could be measured not only as the proportion of clinicians employed as a result of

training, but also by many of the same measures that apply to the physician workforce.

Investments in medical education could result in a number of other returns, both

positive and negative. The aforementioned is merely a sample of the education-related

outcomes and is by no means a comprehensive listing. Indeed, one could argue that many

other intangible benefits accrue that offset monetary losses. But measurement of fiscal









outcomes is important in that it allows us to understand and adjust our current practices to

increase productivity, thereby increasing the other benefits as well.

Justification for the Study

There have been no studies that address the economic impact and ramifications to

society of funding NHSC scholarships for PAs and NPs. While a 1995 GAO report

analyzed and compared costs of the NHSC scholarship and loan repayment program, the

report did not attempt to measure fiscal benefits to society or to the individual that could

accrue from these programs. Scheffler (1975) produced early estimates of private rates of

return for physician assistants. He found that the rates of return for this fledgling

profession-over 20%-were comparable to those of physicians. But these estimates were

based on imprecise data. Since Scheffler's 1975 study the scope of practice, salaries, and

costs of training physician assistants has dramatically changed. Nurse practitioners have

experienced similar advances. Yet there was a paucity of literature describing the impact

of these changes on the current productivity of non-physician clinicians.

Title VII and Title VIII of the Health Profession Service Act provided large

numbers of Federal dollars to education programs for nursing and allied health

professionals through the Bureau of Health Professions and the Bureau of Primary Health

Care. In 2001, approximately $460 million was allocated for health professions

education, including scholarship and loan repayment funds from the NHSC. Almost $100

million of this was devoted to education programs. One of these programs, the NHSC

Scholarship Program, provided $8.4 million in scholarship support to physician

assistants, nurse practitioners, and certified nurse midwives in exchange for service in

HPSAs (Medicare Payment Advisory Commission, 2001).









Since the Federal government devoted such a large portion of the budget to the

funding of medical education and since health care costs were skyrocketing nationwide,

knowledge of the costs and benefits of such programs is important. Analysis of such

programs could facilitate policy change, reallocation of funds and program modification

in order to achieve the most efficient outcomes for the dollars spent. This research will

show what, if any, fiscal benefits may accrue to the individual and/or society from funds

received through the NHSC scholarship program.

Human capital theory holds that education, whether formal or on-the-job, is an
investment both for the individual and the society that devotes resources to
providing it. Individuals decide on how much to invest based on their expected
private return, whereas governments base their decisions to invest or subsidize
human capital on the social return. As an investment, education has been shown to
increase a person's income even after adjusting for the costs of schooling and
adjusting for differences in ability and family backgrounds. For the society, there is
a social return that results from more productive individuals and there is a close
link between education and GDP growth. (Langelett, 2002 p. 10)

This study used a sample of NHSC scholars who completed nurse practitioner or

physician assistant training between 2001 and 2004 to determine, through statistical

analysis and descriptive data, whether societal returns justified the scholarship program

as it is presently structured and administered. Society should expect that funds committed

to the NHSC scholarship program were not wasted.

Waste could be described in a variety of ways. It could be defined by some strictly

as a lack of monetary return from an investment. Payment of Federal taxes could be

viewed as a positive fiscal by-product of NP or PA training. Default of a service contract

resulting in the loss of a potential health care provider in a medically underserved area

could also be viewed as waste.

In a 2001 JAMA report, Rabinowitz, Diamond, Markham, and Paynter (2001)

sought to identify factors independently predictive of rural primary care supply and









retention and to determine which components of the Physician Shortage Area Program

(PSAP) at Jefferson Medical College in Philadelphia, PA, were responsible for the

outcomes. The group found a number of variables such as having a freshman-year plan

for family practice, being in the PSAP, having an NHSC scholarship, being of the male

gender, growing up in a rural community, and taking rural family practice electives were

predictive of physicians practicing in rural primary care. However, they also noted that

only three variables, selecting a rural preceptorship, growing up in a rural area, and

attending college in a rural area, were univariately related to retention. While the study

examined graduates from only a single medical school, it sheds some light on factors that

could apply to health profession students nationwide.

Over time, the characteristics of scholars who were more likely to stay in a service

site beyond their service obligation were identified by the NHSC and were actively

sought during the application process. Scholarship applicants were scored numerically

based on the extent that they appeared to have the following characteristics: (1) strong

primary care post-service career goals in HPSAs, (2) experience within indigent or

underserved communities, (3) understanding and acceptance of the mission of the NHSC

and, (4) intent to participate in pre-professional clinical experiences in rural or urban

community-based health care facilities serving HPSAs (Department of Health and

Human Services [DHHS], 2003). Identification of retention characteristics was

increasingly important as each year of service beyond the initial commitment greatly

increased the positive returns on the scholarship investment.

The success of the NHSC provider training and placement programs could be

measured by how well primary care providers were placed in HPSAs. Shortage areas









with the greatest need should have received additional emphasis and patterns of funding

established with at least some awareness and consideration of expected return on

investment. The assumption could be made that any given non-physician health care

provider had the capacity to create roughly the same societal benefit to a given HPSA

regardless of the institution where the clinician trained. One could also posit that

communities with the greatest need for health care services accrued the greatest benefit

from any given health care provider. It would be only reasonable, then, that scholarship

funds were allocated with some consideration of the HPSA of assignment for each

scholar. By analyzing the fiscal costs and benefits of the NHSC scholarship, the awards

could have been administered in a way that made more efficient use of funds allocated to

the Department of Health and Human Services.

Additionally, this study examined and compared individual costs and benefits of

the scholarship program for NPs and PAs. A fully funded 2-year scholarship program

with over $26,000 in stipends plus allowances for books, equipment and travel expense

reimbursements appears to be a good investment for the scholar. But foregone earnings,

tax liabilities and other school-related expenses could have created significant differences

in the degree of personal financial return between PAs and NPs.

The results of this study are important because they reported the fiscal costs and

benefits of funding a Federal program aimed at providing primary health care services to

underserved populations in the most efficient manner possible. These results should be

useful in analyzing and comparing existing scholarship and loan repayment programs and

in the development of models for future programs.









If the results of this study imply that the NHSC scholarship for PAs and NPs was

an inefficient fiscal investment for society, the NHSC should carefully examine how

funds were distributed, how providers were placed, and which methods were used to

measure outcomes in underserved areas. It is entirely possible that the number of social

and global economic benefits that accrued outweighed financial costs. But those benefits

could also have been maximized as a result of changes in the program.

Limitations

Upon graduation and employment the scholars enjoyed enhanced income

generation abilities. This was one means of validating investment returns. Such income

allowed the scholars to purchase additional goods and services as well as generate

additional tax revenues. The results of this study reported the years of income needed to

repay the NHSC scholarship program investment through additional tax revenues

generated.

It is evident that many costs and benefits, societal and personal, resulting from the

NHSC scholarship program were ignored in this study. Those costs and benefits deserve

additional study. This research was limited to monetary value considerations.

There were a number of other limitations to this study. Some of these limitations

include the following:

1. The study was limited to 187 participants from four selected year groups of
NHSC physician assistant and nurse practitioner scholars whose
demographic and financial data were available through surveys, and in
government and professional association databases. Scholars with invalid
addresses on file with the DHHS and non-respondents were not included in
the study. Forty percent of potential participants did not respond to the mail
survey.

2. The study was limited to a review of investment returns through increased
income generation due to employment at HPSA sites following NP or PA









training using NHSC scholarship funds. Additional income from related
activities such as public speaking or moonlighting was not considered.

3. The study was limited to NHSC scholarship recipients. No comparison was
made to other types of financial aid for health care providers. Similarly,
income and obligations from other sources of financial aid were not
considered in any comparisons.

4. Unique tax filing circumstances were not considered. For the purposes of
this study a special report by the tax foundation (Moody & Hoffman, 2003)
was used to estimate the average Federal tax burden on the American wage
earner. Tax revenues were estimated by determining mean personal income
of the subjects and applying the appropriate tax rate for that income bracket.
Marriage, divorce, adoption or other changes to their tax-filing status could
influence the amount of taxes paid by each of the subjects over the period of
years studied.

5. Differences in training programs between schools and between years at the
same school were not measured. While differences and variations in
individual learning experiences are bound to exist, all of the programs are
required to meet the standards of their respective accrediting bodies. These
standards ensure that each program's curriculum is rigorous enough to
produce competent clinicians capable of passing national certification
examinations.














CHAPTER 2
REVIEW OF THE LITERATURE

This research concerns the National Health Service Corps (NHSC) Scholarship

Program; therefore the literature review emphasized the Federal government's

involvement in education and health care. While the NHSC also awarded scholarships to

physicians, dentists and nurse-midwives, this research explored the funding of education

for nurse practitioners (NPs) and physician assistants (PAs).

The Maldistribution of Health Care Providers in the United States

Accurate and meaningful measurement of the U.S. health workforce has always

been an enormous task. This was due, in part, to the lack of consensus and varying

definitions of workforce composition. The task was further complicated by the

multiplicity of data sources including the Department of Labor (DOL), Department of

Health and Human Services (DHHS), and a number of private organizations. To add to

this confusion, studies involving measurement of the health workforce often did not

consider the roles of non-physician clinicians (Matherlee, 2003).

The Secretary of the Department of Health and Human Services has designated

numerous facilities, geographic areas, and population groups as Health Profession

Shortage Areas (HPSAs). These were identified on the basis of agency or individual

requests for such designation. The HPSA designation qualified these areas for Federal aid

in the form of grants, enhanced Federal insurance reimbursements, and placement of

NHSC practitioners.









A Federally Qualified Health Center (FQHC) was a type of provider defined by the

Medicare and Medicaid statutes. This included all organizations receiving grants under

section 330 of the Public Health Service Act. Federally qualified health centers received

automatic HPSA designation.

Non-automatic HPSAs were scored using a point system based on four factors: (1)

population to primary care physician ratio, (2) percent of the population with incomes

below 100% of the poverty rate, (3) infant mortality and low-birth weight rates, and (4)

travel time or distance to the nearest available source of care (Health Resources and

Services Administration [HRSA], 2004b).

The population to primary care physician ratio generated up to ten points and each

of the other four factors generated up to five points toward a maximum possible HPSA

score of 25. Scholarship-eligible sites usually had a HPSA score of at least 15. Data used

in scoring HPSAs came from a number of sources. Population and poverty data usually

came from available U.S. Census information. In most cases, infant mortality/low birth-

weight rates came from county-level sources. Most facilities did not qualify for points in

this category and it was unusual for any facility to score higher than one or two points.

Provider data included all non-Federal providers without NHSC obligations or J1 visa

waiver obligations. Travel time and distance estimates were based on Primary Care

Service Area (PCSA) and Graphic Information System (GIS) road classification data.

These were sometimes modified based on local data (HRSA, 2004b).

According to a fact sheet developed by the North Carolina Rural Health Research

Program, the Department of Health and Human Services used a ratio of one primary care

physician per 3,500 population or more as the standard for a primary care HPSA









designation. The same department's recommended ratio for an "adequately served"

population was one primary care physician per 2,000 people. In 1997, over 2,000

physicians would have been required in non-metropolitan areas in order to remove the

HPSA designations. More than twice that number would have been required to meet the

"adequately served" 2,000:1 ratio (HRSA, 1997).

In 1986, Congress authorized the Council on Graduate Medical Education

(COGME) to provide an ongoing assessment of physician workforce trends and to

recommend appropriate efforts to address identified needs. The tenth report, published in

1998, examined physician distribution in rural and inner-city areas. Rural areas seemed to

be particularly hardest hit by shortages. Only about 9% of physicians in the United States

practiced in rural areas despite the fact that roughly 20% of the population- about 50

million people-resided in rural communities (Council on Graduate Medical Education

[COGME], 1998). The Bureau of Health Professions area resource files (Dill et al., 1996)

demonstrated an inverse relationship between county population size and primary care

physicians per 100,000 residents. Counties with populations greater than 50,000 had over

50 physicians per 100,000 while those with fewer than 2,500 residents had less than 20

per 100,000 residents.

According to the Federal Office of Rural Health Policy, persons living in non-

metropolitan areas were nearly 4 times more likely to live in a HPSA than persons in

metropolitan areas (HRSA, 1997). In a report of conference proceedings from the 5th

International Medical Workforce Conference, Gary Hart (2000) cited the Rural Policy

Research Institute (RUPRI) to further characterize the vulnerability of rural populations.

He explained that, according to RUPRI, rural U.S. populations had relatively more









elderly and children, unemployment or underemployment, and poor and uninsured

residents. Additionally, these populations were more vulnerable to economic downturns

than their urban counterparts. More serious, Pol (as cited in Hart, 2000) stated that during

the 10th decade of the last century, the percentage of the rural population under 65

without health insurance increased 11% to approximately 7 million (15.7% of the rural

population).

More than 40 million adults and children in the United States were uninsured in

2000. When they sought health care, they often utilized a patchwork of unrelated

community providers who were willing to care for them. This included a number of

hospitals, community health centers, rural health clinics and a host of other providers.

Care for the uninsured created challenges that left few resources to devote to creating an

infrastructure to ensure continuity of care across providers (U.S. Congress, 2001).

Ricketts, Johnson-Webb, and Randolph (as cited in Hart, 2000) described rural

health status as generally similar to that of urban areas. He also asserted that rural

residents experienced increased risks from auto, gun, and farm accidents, and exposure to

pesticides and herbicides, as well as an overall increase in the prevalence of chronic

disease.

HPSAs were designated and ranked according to a number of statistics, namely, the

availability of health care providers. The ratios used to designate HPSAs did not,

however, consider contributions made by health care providers who were not physicians.

Data definitional problems and differences in State laws also made estimation of non-

physician Clinician (NPC) impact on the health care workforce difficult. Yet NPCs, such

as physician assistants and nurse practitioners, were becoming increasingly important









providers of medical care services. As of 2003, approximately 110,000 PAs and NPs

comprised approximately one-sixth of the physician work force. Their productivity and

range of services approached 90% of what a primary care physician provided. The supply

of NPCs was increasing. As of 2002, the annual number of PA and NP graduates had

risen to 12,000. This number rivaled the 17,000 medical graduates produced each year

(Hooker, 2003). Cooper, Laud, and Dietrich (as cited in Hart, 2000) estimated that the

number of trained nurse practitioners would nearly double by 2015.

Gamm, Castillo, and Pittman (2003) asserted that non-physician clinicians

appeared to slightly favor rural settings, provided needed primary care, and in most cases,

costed less and were better able to conform to the resource constraints in rural areas than

physicians. Baer and Smith (as cited in Gamm and Pittman, 2003) made the point that

among the 55,730 active nurse practitioners and 31,084 physician assistants in 1996, a

large percentage practiced in rural or urban settings. NPs and PAs in rural settings

numbered 24.72 and 11.91 per 100,000 population, respectively; for the urban

populations the numbers were slightly smaller at 20.08 and 11.66, respectively.

Very little research has been done to examine characteristics of non-physician

clinicians and their decisions to practice in non-metropolitan versus metropolitan areas.

Many of the same factors that influenced physicians may have also shaped the location

decisions of non-physician clinicians and their dedication to practice in underserved

areas. Rabinowitz et al. (2001) found that having an NHSC scholarship, being of the male

gender, and taking an elective senior family practice rural preceptorship were

independently predictive of physicians practicing in rural primary care. In their study,









participation in a physician shortage area program was the only independent predictive

factor of retention.

A study by Fowkes, Gamel, Wilson, and Garcia (1994) suggested that older PA and

NP students who clearly identified practice goals and had backgrounds in underserved

areas were more likely to practice in such areas after graduation. It also seems plausible

that clinicians with families would have been more likely to remain in one geographic

location as children attended schools and developed circles of friends.

Characteristics of the site, such as scope of practice, turf conflicts, and

reimbursement issues were also important to physicians. It is reasonable to assume that

many, if not all, of these factors applied to PAs and NPs. Additionally, acceptance of

non-physician clinicians by the local medical community may have played an important

role in NPC retention.

From the literature it appears that reimbursement was not a strong incentive for

clinicians serving in non-metropolitan areas. A report by the Federal Office of Rural

Health Policy (1996) asserted that non-metropolitan physicians derived a larger share of

their gross practice revenue from public programs that pay lower rates, such as Medicare

and Medicaid. Conversely, metropolitan physicians served more patients with higher

paying private insurance. Commonly used indicators of physician work load in 1995

indicated that non-metropolitan physicians worked longer hours and had more patient

visits per week than their metropolitan counterparts (Federal Office of Rural Health

Policy, 1996).

In a National Health Policy Forum Background Paper, Karen Matherlee (2003)

provided a comprehensive view of the structure of the health workforce as well as public









and private insurance coverage and payment policies. Her assertion was that the health

workforce "follows the dollars" of public (Medicare and Medicaid) and private insurers.

She described Medicare as the "standard bearer" for many private insurers. Medicare

covered eligible persons over 65 and younger people with qualifying disabilities. This

made Medicare the largest payer for most hospitals and many practitioners and therefore

a major influence on the health workforce.

Reimbursement for services provided also impacted a provider's decisions

regarding practice location. Certain practitioners could receive direct payments from

Medicare and others could not. According to a 2002 Medicare Payment Advisory

Commission report to Congress (as cited in Matherlee, 2003), nurse practitioners

received 75-85% and physician assistants received 85% of the physician fee when they

provided services within their legal scopes of practice. If, however, they provided these

services under the direct supervision of the physician they billed directly under the

physician's number (billing incident to physician services) at 100% of the fee schedule.

Medicaid, a Federal-State entitlement program for certain persons and families with

low incomes and resources, was another large source of funds to health providers in

underserved areas. This public program allowed states a great deal of flexibility to

administer their own plans. The Federal government provided matching funds to the

states and outlined certain requirements. "A state's Medicaid program was must to offer

medical assistance for certain basic services to most categorically needy populations."

(Matherlee, 2000, p. 11) Matching funds were also available for 34 optional services.

Some states have undertaken initiatives to give different types of incentives to

practitioners who selected certain specialty and practice locations. Because the states had









considerable flexibility in program administration, there was great variation from state to

state in a practitioner's legal scope of practice and payment rates. All State programs

covered medical services provided by NPs and PAs in fee-for-service and managed care

plans either at the same rate or a lower rate than was paid to physicians (Matherlee,

2003).

The Use of Non-Physician Clinicians

At the time of this study, non-physician clinicians were well into their fourth

decade of history in American medicine. They were employed by over one-quarter of all

group practices and provided a major source of access in many large health maintenance

organizations (Hooker, 2003).

The physician assistant and nurse practitioner professions were initially created as a

strategy to address health care needs caused by a nationwide shortage of physicians.

Many practices later employed them for a number of other reasons. Non-physician

clinicians were trained in a much shorter period of time at a much lower cost than

physicians. When this was coupled with the lower salary ranges, these clinicians became

a cost-efficient way to improve the productivity of a practice.

An analysis by the U.S. Congress Office of Technology Assessment concluded that

within their areas of competence, nurse practitioners and physician assistants provided

health care whose quality was equivalent to that of care provided by physicians. Further,

some studies indicated that these midlevel practitioners were more adept at providing

supportive care, health promotion activities and services that depended on

communication with patients (U.S. Congress, 1986).

More important, an NPC could handle routine office visits, see acute patients

quickly, provide in-depth patient education, and perform a number of other routine tasks,









freeing the physician to concentrate on more complex cases, handle practice management

tasks, or just spend a few extra hours each week at home.

Many practices used NPCs to handle overflow of patients and cover scheduled

appointments when the physician was called away from the office for emergencies. Their

flexibility and willingness to shift where demand for medical services was greatest made

them an asset in a medical practice environment that was rapidly evolving. Other

practices used NPCs to boost productivity and augment clinic services.

But a study by Shi, Samuels, Ricketts, and Konrad (1991) examined major factors

influencing the use of NPCs in rural community and migrant health centers based on

national survey data. The study demonstrated a significant but inverse relationship

between the number of physicians and the number of NPCs employed. This finding

suggested that NPCs primarily served as substitutes for physicians in rural community

and migrant health centers.

In many work settings nurse practitioners and physician assistants provided

comparable services and enjoyed similar scopes of practice. Yet the differences between

the advanced nursing practice approach used by NPs and the medical model employed by

PAs also allowed these two groups to offer a more diverse array of health care services

when working side by side. With this in mind, it is useful to highlight the characteristics

of the two professions.

Nurse Practitioners

Nurse practitioners were registered nurses (RNs) with advanced academic and

clinical experience. They were trained to take principal responsibility for the diagnosis

and management of uncomplicated illness either independently or as part of a health care

team. NPs provided a full range of primary care services in the community setting and









made decisions about their patients' nursing needs. In some states, they had the authority

to independently prescribe medications.

They were able to spend more time with their patients and provide education and

counseling on wellness and disease prevention. Some nurse practitioners developed and

implemented community programs dealing with issues such as self-help or group therapy,

parenting, nutrition, and stress reduction. Many worked under the supervision of a

physician. In their practice they often collaborated with other health care professionals on

matters regarding patient care.

Their clinical knowledge and experience as RNs, coupled with their advanced
clinical training, enables NPs to work with patients on a wide range of clinical
tasks. NP practice blurs the discipline boundaries between nursing and
medicine so their services can both substitute for and complement the care of
physicians (HRSA, 2004a p.4).

Profile

In 1992 there were approximately 28,000 NPs practicing in the U.S. In an 8-year

period the number rose 240% to more than 95,000 in 2000 (HRSA, 2004a). By 2004

there were 106,000 NPs practicing in the U.S. (American Academy of Nurse

Practitioners [AANP], 2004). Approximately 96% of NPs were female and their mean

age was 46. About 85% of them worked in primary care. Approximately 58% of NPs

worked more than 32 hours per week (Hooker, 2003).

Training

The typical training program ranged from 15 to 36 months in length (with a mean

of 26 months.) In 2002 these programs produced almost 7000 graduates. The programs

taught assessment, diagnosis and intervention as an extension of nursing practice. At least

80% of NPs graduated with a master's degree (Hooker, 2003). According to a report by

Nurse Practitioner Alternatives (NPA), over 83% of nurse practitioners were certified in









family and adult advanced practice nursing (Nurse Practitioner Alternatives [NPA],

2004).

By the end of the 20th century there were 321 institutions sponsoring nurse

practitioner training programs. Around 72% of the graduates of these programs trained in

primary care disciplines such as adult, family practice or pediatrics. Nurse practitioner

education programs were accredited by the National League for Nursing Accrediting

Commission, the National Association of Nurse Practitioners in Women's Health, and the

Commission on Collegiate Nursing Education (HRSA, 2004a).

Scope of Practice

Most states required NPs to pass an examination from one of four certifying bodies;

the American Academy of Nurse Practitioners (AANP), the National Certification

Council for the Obstetric, Gynecologic and National Nurse Specialties (NCC), the

American Nurses Credentialing Center (ANCC), or the National Certification Board of

Pediatric Nurse Practitioners and Nurses (NCBPNP/N) (American Association of

Colleges of Nursing [AACN], 2005).

Clinical activities for NPs were usually regulated by the State Board of Nursing. In

nursing care functions, NPs were professionally autonomous. Most states, however,

required them to work in collaboration with a physician. They were allowed to practice

independently in 16 states, and in 10 of those they prescribed independently (Hooker,

2003).

The roles, responsibilities and privileges of NPs varied greatly depending upon the

jurisdiction in which they practiced. In many states, the legislation defining scope of

practice treated PAs and NPs fairly equally. But some states treated them unequally,









providing a competitive advantage for one profession over the other (Wing, Langelier,

Continetti, Slocum, & Salsberg, 2003).

Salaries

A 2003 national salary of nurse practitioners showed the average salary as $69,203

for full-time nurse practitioners. This was up 9.55% from the $63,172 average in 2001.

The survey also demonstrated differences based on practice setting. NPs working in

urban areas fared best, with salaries averaging $70,040, followed closely by those

working in suburban areas, who made an average of $69,835. Nurse practitioners in rural

areas reported an average salary of $66,842 (Tumolo & Rollet, 2004). According to the

same survey, masters-prepared NPs made only around $1,200 per year more than those

with bachelor degrees ($67,951 and $69,144, respectively). Those with doctoral degrees

who worked outside of academic settings earned $77,243.

Work Settings

In 2004, almost 60% of NPs were practicing in ambulatory settings, including

HMOs, school health, and private clinics and offices. Among these clinicians, 4.7%

described their practices as independent (NPA, 2004).

Productivity

Nurse practitioners averaged about 75 outpatient visits per week (Hooker, 2003).

Hooker also asserted that productivity of non-physician clinicians (NPCs) in a managed

care setting was generally 10% higher than physicians in a similar or same setting. He

further explained that this was due to the collateral roles and hospital responsibilities of

physicians that took them away from the clinic.









According to a 2004 report (NPA, 2004) the majority of NPs saw between 11 and

15 patients per day. Only 21% of nurse practitioners surveyed reported more than 20

patient encounters per day.

Physician Assistants

Physician assistants (PAs) were trained to provide health care services under the

supervision of physicians. The level of supervision, direct or indirect, varied depending

on experience, the task performed, the legal environment and practice setting. PAs should

not be confused with medical assistants, who performed routine clerical and clinical

tasks. Physician assistants performed diagnostic, therapeutic, and preventive medical

tasks as delegated by their supervising physician. This may have required them to take

medical histories, perform physical examinations, order laboratory tests and x-rays,

diagnose illnesses, and prescribe medications. PAs also treated minor injuries by

suturing, splinting, casting, and performing other therapeutic procedures. Patient

education and counseling was another important service provided by physician assistants.

While PAs worked under the supervision of a physician, they were sometimes the

principal provider in clinics where a physician was only occasionally present or was

primarily available by phone. PAs consulted with their supervising physician or other

health care professionals as needed or required by law. The duties of the PA were

determined by the supervising physician in accordance with State law (U.S. Department

of Labor, 2004).

The American Academy of Physician assistants (AAPA) estimated that there were

approximately 61,871 individuals eligible to practice as physician assistants during 2004.

Physician assistants practiced in at least 61 specialty fields. According to a 2004 census,

42% of the respondents reported their primary specialty as one of the primary care fields:









family/general practice (30%), general internal medicine (8%), obstetrics/gynecology

(3%), and general pediatrics (3%). Other prevalent specialties included emergency

medicine (10%), surgery (23%), and internal medicine subspecialties (10%) (AAPA,

2004).

Profile

In a 2003 census of new enrollees in physician assistant programs, females

accounted for 71% of respondents. The mean age of the newly enrolled students was 28.1

years. Three fourths had no dependents at the time of the census; one fourth report at

least one dependent. The census also revealed that 76% of respondents were students

during the 12-month period prior to PA school. Half of these were full-time students and

half attended part-time. Approximately 58% were previously employed full-time in a

health care field. In 2002, the average pre-PA student had worked 3.1 years in a health

care field with direct patient contact prior to PA school (AAPA, 2003a).

Education levels of new applicants ranged from high school diplomas to doctoral

degrees with 89% of respondents having 4 years or less of college. PA students come

from a wide variety of backgrounds. Unlike nurse practitioner students who were all

nurses prior to matriculation, PA students came from a number of medical-technical

positions such as EMT/paramedic (17%), medical assistant (17%), emergency room

technician (8%), and phlebotomist (9%). Only about 4% of PA students were registered

nurses. Other types of nurses account for 8% of PA students (AAPA, 2003c).

Physician Assistant Training

In 2002 there were 133 accredited physician assistant training programs in the

United States. Among these programs, 68 of them offered a master's degree. The rest

offered a bachelor's or an associate's degree. Most applicants (79%) to PA programs in









2003 had already earned at least a bachelor's degree (U.S. Department of Labor, 2004).

Despite the variety of degrees offered, most PA program curricula were very similar in

structure and length.

Physician assistant training programs usually lasted at least 2 years and included

classroom instruction in biochemistry, clinical pharmacology, clinical medicine, human

anatomy and physiology, disease prevention and medical ethics. Similar to medical

students and residents, PA students obtained supervised clinical training in several areas,

including primary care medicine, inpatient medicine, psychiatry, surgery, obstetrics and

gynecology, geriatrics, emergency medicine, and pediatrics.

Some PAs pursued additional education in specialties such as surgery, neonatology,

or emergency medicine. PA postgraduate training programs were also available in areas

such as internal medicine, rural primary care, emergency medicine, surgery, pediatrics,

neonatology, and occupational medicine.

All states required graduates from accredited PA programs to pass the Physician

Assistant National Certifying Examination (PANCE) to become eligible to practice.

Afterwards, they were required to log 100 hours of continuing medical education every 2

years and pass the Physician Assistant National Recertification Examination (PANRE)

every 6 years.

Salaries

Physician assistant salaries vary by location, specialty, and years of experience.

According to a 2004 census by the American Academy of Physician Assistants, the

median annual income for physician assistants with an average of 6 years of clinical

experience was $74,264. This was up from $65,783 the previous year. Individuals in the

10th percentile earned $57,823 while those in the 90th percentile earned $103,614.









Approximately 24% of respondents reported receiving some type of bonus or incentive

pay and 18% received overtime pay. Other forms of reported compensation included

funds for malpractice insurance, licensing, credentialing, professional dues and

continuing medical education. Respondents who graduated in 2003 reported a median

starting salary of $65,783. This was an increase from the previous year survey amount of

$63,437 (AAPA, 2004b).

Scope of Practice

Depending on the setting, physician assistants could perform roughly 80% of the

routine tasks that physicians normally perform. These tasks included obtaining medical

histories, performing physical examinations, and diagnosing and treating illnesses and

injuries. They also performed a number of procedures such as suturing, lumbar punctures,

thoracenteses, paracenteses, and central line placements. PAs worked under the delegated

authority of a physician and they were not allowed to perform tasks that were not within

the scope of practice of their supervising physician. The scope of practice in some states

was very broadly defined; other states restricted the scope of practice in such detail that

performance of routine tasks was limited.

Work Settings

PAs worked in a diverse array of settings. From military battalion aid stations,

hospitals, and correctional institutions to private practices, community health centers, and

inner city clinics, almost one fourth of PAs were located in rural and frontier

communities (Cawley, 2002).

In 2004 only 8% of practicing PAs worked in Federally Qualified Health Centers,

correctional facilities or other community health centers. Of the respondents practicing in









fields generally in demand at HPSA clinics, 30% practiced in family/general medicine,

3% in general pediatrics, and 8% in general internal medicine (AAPA, 2004).

When new enrollees to PA programs were asked about an intended specialty area,

only 40% indicated family/general practice and 26% were undecided. Approximately

80% of respondents indicated that they would be willing to practice in a medically-

underserved area, yet only 32% expressed an intention to practice in such areas (AAPA,

2003a).

Productivity

Roughly 88% of PAs worked more than 32 hours and averaged about 105 patient

visits per week. In a report on non-physician clinicians in the U.S., Hooker (2003) cited a

medical group management association (MGMA) survey that described the

compensation-to-production ratio, (the salary and benefit cost to employ a provider

compared to the revenue generated from their services.) This ratio was 0.38 for PAs, 0.41

for NPs, and 0.49 for family physicians. This was, perhaps, because PAs were paid

substantially lower salaries than physicians and they saw a comparable number of

patients per day. This made NPC utilization quite profitable for health care organizations

at certain levels of medical care. The MGMA survey data also indicated that for every

dollar a PA generated, 26 cents went to pay the PA (Medical Group Management

Association (MGMA) as cited in Hooker, 2003).

Larson, Hart, and Ballweg (2001) estimated the productivity of a nationally

representative sample of PAs at 83% of that of physicians. They reported that the PAs

performed 61.4 outpatient visits per week compared to 74.2 visits performed by

physicians. The authors go on to say that rural PA productivity was higher than urban

productivity due to the concentration of generalist PAs in rural settings.









Assistance to Health Profession Shortage Areas

Since the 1970s financial support for the education of health care providers to serve

in shortage areas has been provided primarily through a few foundations and a number of

government programs. Some programs were designed to facilitate the training of new

health care providers or to influence them to practice in shortage areas. Other programs

improved reimbursement for existing health care providers in underserved areas.

Medicare

The role of Medicare in (1) funding of Graduate Medical Education (GME) and (2)

enhanced reimbursement played an enormous role in the preparation and support of

health care providers serving HPSAs. Direct GME funds covered residents' salaries and

fringe benefits, allocated hospital overhead connected with training programs, and other

costs. Indirect GME dollars were added to inpatient prospective payment of diagnosis-

related group rates in order to recognize the additional costs teaching hospitals incur as a

result of their teaching programs. According to Matherlee (2003), Medicare GME outlays

in 2000 were approximately $7.8 billion.

Medicaid

Medicaid was a Federal-State entitlement program aimed at low-income and

resource-poor individuals. While states were required to offer medical assistance for

certain basic services to most categorically needy populations, the system provided states

with a great deal of flexibility to administer plans in ways that best met the needs of their

recipients. Matching funds were also available for a number of optional services.

Under Federal-State arrangements, states were responsible for purchasing health

care services and paying health care providers. Most states, however, contracted with

health plans under managed care arrangements. The flexibility of the program allowed a









number of states to create incentives for practitioners who selected certain specialty areas

and practice locations. Payment rates and legal scopes of practice varied from state to

state (Matherlee, 2003). According to Heinrich (USGAO, 2000) Medicaid became the

largest source of health care revenues for community and migrant health centers. In 1998,

health centers reported revenues of almost $3 billion.

Foundations and Trusts

For many years the W. K. Kellogg Foundation, the Pew Charitable Trusts, and the

Robert Wood Johnson Foundation offered philanthropic support to programs that sought

to improve the availability of community-based medical care and primary care

practitioners (Matherlee, 2003).

The W.K. Kellogg Foundation was created in the 1930s to prepare health care

providers with the values, skills, and perspective associated with promoting health and

preventing illness and with community in its broadest sense. Since then the Foundation's

programs brought together educational institutions with community-based organizations

to improve health professions education.

The Pew Charitable Trusts embarked on a four-part strategy to appropriately train

health care providers and improve the provision of primary and population-based health

care. The strategy involved defining the system and the roles and responsibilities of the

practitioners, determining financing changes necessary to support shifts in training,

redirecting training to community-based outpatient settings, and educating the public

about primary care services and how to use them more effectively.

The Robert Wood Johnson Foundation's programs related to primary care

workforce development covered several categories. These included training and

leadership development, enhancement of generalist physician training programs,









development of primary care practice in communities, and improvement of diversity of

the health care workforce (Matherlee, 2003).

Public Health Service Act

The Federal government, through Titles VII and VIII of the Public Health Service

Act (PHSA) supported a number of efforts aimed at training health professionals to serve

in shortage areas. Title VII covered medical, dental and allied health. Title VIII covered

general and advanced practice nursing (Matherlee, 2003). A number of initiatives fell

under the umbrella of these two titles:

The Minority and Disadvantaged Health Professions Initiative provided support to

health professions and scholarships to disadvantaged and minority students who attended

a health professions or nursing school. This included Centers of Excellence Programs,

the Health Careers Opportunity Program, the Scholarship for Disadvantaged Students

Program, and the Faculty Loan Repayment Program.

Primary care medicine and dentistry programs promoted training of practitioners

including general pediatricians, generalists in internal medicine, family physicians,

dentists, and PAs. The Geriatrics Health Professions Program supported geriatric faculty

fellowships, entry of geriatric physicians into academic medicine, and geriatric training in

schools.

The Quentin N. Burdick Program for Rural Interdisciplinary Training strengthed

the distribution, diversity, and quality of health care practitioners by providing

opportunities for collaboration among academic institutions, rural health care agencies,

and health care professionals.

The National Center for Health Workforce Analysis collected and analyzed data on

the health care workforce in an effort to help State and local planners. The center









conducted workforce issue analyses, evaluated training programs, and conducted research

on the health workforce.

The PHSA, through Title VIII, provided for public health workforce development,

nursing education initiatives and nursing workforce development as well as loans for

needy and disadvantaged medical and nursing students (Matherlee, 2003).

Area Health Education Centers

The Health Resources and Services Administration (HRSA) encouraged students to

take advantage of training opportunities by serving the health care needs of underserved

communities. This was done with financial support to Area Health Education Centers

(AHECs) as authorized by the PHSA. These centers served the communities by

extending the resources of academic health centers into rural areas and providing clinical

training opportunities for health professions and nursing students (National Rural Health

Association [NRHA], 2003).

The AHEC initiative enjoyed great success since the inception of the first

generation of centers in 1972. A second generation of AHECs began in 1977, followed

by a third generation in 1984. Unlike the first-generation AHECs, subsequent generations

placed greater emphasis on non-physician clinician education (Bernstein, 1990).

Each of the AHECs was eligible for Federal funding for up to 9 years. During this

time State and local governments contributed at least 25%. The goal was to eventually

function without Federal funding. As of 1998, over 23 AHEC programs were functioning

without Federal funding and eighteen more were moving toward independence.

The AHECs differed greatly in their unique goals and priorities. These centers were

involved in a wide variety of activities designed to meet the needs of the local

populations and the students. In Southwestern border-states they emphasized recruitment









of health professionals to serve Hispanic communities while others targeted Native

American and Black populations. Urban AHECs often concentrated on graduate medical

education, health profession career opportunities, undergraduate medical education,

health education and nutrition programs. Rural AHECs, on the other hand, emphasized

nursing education and continuing professional education, and provided strong support for

area NHSC clinicians.

The continued success of the AHECs resulted in a relatively stable funding history.

As of 1990, appropriations for these programs totaled $18.5 million. The decentralized

clinical education experiences made possible by the AHECs provided confirming

education for health professionals in remote communities. These experiences often

influenced health care providers to make the decision to serve in a HPSA after graduation

(Bernstein, 1990).

National Health Service Corps

Initially enacted by the Emergency Health Personnel Act of 1970 to respond to

geographic maldistribution of primary care professionals, the NHSC was later authorized

under Title III of the PHSA. The NHSC, which offered scholarship and loan repayment

dollars in return for obligated service in shortage areas, has gone through periods of

fluctuating fiscal support.

In 1972, the NHSC scholarship program was created, followed by the loan

repayment program in 1987. The NHSC loan repayment program was accompanied by a

State Loan Repayment Program created in the same year. Under the State Loan

Repayment Program, states were encouraged to create loan repayment programs similar

to the NHSC program. The Department of Health and Human Services was to then fund

up to 75% of the total costs through a grant to the state.









The 1980s were particularly hard years for the NHSC scholarship program.

Appropriations fell from $63.8 million in FY1981 to $0 in FY1989 and FY1990. In 1987,

Congress initiated the NHSC loan repayment program under which the Corps would

repay educational loan obligations incurred by health care professionals in exchange for

obligated service in HPSAs.

The 1990s saw a revitalization of the programs and the number of HPSA

designations increased dramatically. Between 1990 and 1994, Congress increased NHSC

program funding in response to an increase in the number of HPSAs. As a result, the

number of health professionals with scholarship obligations increased precipitously and

the funding continued to increase in the years following, from $112.4 million in FY1998

to $115.3 million in FY1999, $116.9 million in FY2000, and $125 million in FY2001.

However, this still met less than 13% of the current need for primary care clinicians in

HPSAs (U.S. Congress, 2001). In FY 2002, $90 million in NHSC scholarships and loan

repayments were awarded to health care clinicians (Duke, 2002).

The scholarship program remains a vital piece of the NHSC package. As a result of

the Public Health Service Act, at least 40% of NHSC funding was required to be used for

scholarships (USGAO, 2000). In 2003 an estimated 522 new and 70 continuing

scholarships were awarded, obligating roughly $39.6 million. The total estimate for FY

2004 was $57.2 million (NHSC, 2004c).

Economic Incentives for Community Health Centers

In addition to financial support for education of health care providers, a number of

economic incentives were available to establish and maintain the community health

centers that provided training and future employment opportunities to students. Barnes et

al. (2004) outlined six strong economic incentives for these organizations. These include









(1) Section 330e grant funding, which allowed communities to receive up to $650,000 in

Federal grant dollars to establish and operate health centers; (2) malpractice insurance

coverage under the Federal Tort Claims Act; (3) access to medicines at a discounted rate

through the 340B drug pricing program; (4) Enhanced Medicaid reimbursements; (5)

State and local funding and donations; and (6) health care provider recruiting assistance

through the NHSC.

Federal Support for Higher Education

In accordance with the tenth amendment of the U.S. Constitution, responsibility

and authority for funding higher education belongs to each of the 50 states. But the

Federal government has a long and diverse history of increasing support for higher

education. This history is marked by a number of significant events. A few of these

milestones deserve mention in that they help build an understanding of the current

Federal financial aid environment. Beginning with the Land Grant College Acts of 1862

and 1890, Federal support has served to stimulate the growth of public higher education

in the United States. These Acts also forged a link to economic development of the

industrial classes through higher education.

Following the Second World War, the Serviceman's Readjustment Act of 1944,

also known as the GI Bill, opened the door to a broad middle class that built upon the

research partnerships that had developed between the Federal government and higher

education. The benefit covered all tuition, books and fees along with a monthly stipend.

In the peak years of the program the costs amounted to $2.7 billion, almost 1% of the

gross national product. According to Prisco, Hurley, Carton, & Richardson, (2002), the

GI Bill marked the emergence of the most significant Federal role in higher education

and set in motion the growth and expansion of numerous public institutions.









In the late 1950s the launch of Sputnik by the Soviet Union started a space race

which resulted in the creation of the National Defense Student Loan (NDSL) program.

The program, which sought to increase the U.S. supply of scientists and teachers by

forgiving up to half of a student's loan in exchange for service teaching science, math, or

a foreign language, later became known as the Perkins loan program (Shapiro, 1994).

In 1964 the civil rights act, Title IX of the Education Amendments of 1972, and the

Americans with Disabilities Act of 1991 opened the doors to even more Americans.

Higher education institutions continued to respond to calls for diversity inspired by these

changes.

In 1965 President Lyndon B. Johnson signed the Higher Education Act which

sought to ensure access to higher education institutions for high school seniors regardless

of their financial status. Backed by an unprecedented $804 million, the bill effectively

shifted the focus of Federal support from areas defined as national priorities to those of

community service, continuing education, library assistance, and teacher programs

(National Education Administration [NEA], 2003).

The Federal government also supported higher education through a number of

student assistance programs, tax policies, and research support. Following the NDSL

program of 1950s, the 1960s saw several programs emerge that were designed to fight the

war on poverty. Through the Guaranteed Student Loan program, for instance, the Federal

government guaranteed loans to economically disadvantaged students. Similarly, the

Supplemental Educational Opportunity Grant (SEOG) program distributed funds to

institutions of higher education to provide grants to needy undergraduate students. In the









1970s, the largest Federal grants program in history, the Pell Grant program, began

making grants available to undergraduate students in need (Prisco et al., 2002).

In addition to the numerous loan and grant programs, a number of tax programs

were favorable towards institutions and their students. Wolanin (NEA, 2003) estimated

that Federal tax benefits afforded to institutions of higher learning could be valued at

approximately $50 billion per year.

Individual tax credits could be appreciated in the form of tax-free scholarships as

well as tax credits and deductions. The Taxpayer Relief Act of 1997 created one of the

largest and most expensive tax benefit programs for higher education expenses in history.

Conklin (as cited in NEA, 2003) described the resulting Hope tax credit as a program so

large that when taxpayers fully use the tax credits, the cost to the government could easily

exceed the cost of all other existing Federal financial aid programs combined.

Research support was another large source of funding for U.S. colleges and

universities. According to a 2002 American Association for the Advancement of Science

intersociety working group report (as cited in NEA, 2003), Federal sources were

responsible for $17.5 billion of funds for research in higher education. The lead

supporters of research funding for higher education were the National Science

Foundation and the National Institutes of Health.

Despite the appearance of an enormous increase in support for higher education,

McPherson and Shapiro (1997) contended that State governments have been decreasing

the appropriations to public colleges and universities and that the burden of college costs

had been shifted to students and families through increased tuition. They pointed to a

26% increase in tuition in 1979-1980 and a 35% rise in 1992-1993. They further









explained that higher costs were restricting college options for some lower income

students and that Federal student aid programs failed to keep pace with the increases.

Recent Federal Involvement in Higher Education

A 2001 report to the U.S. Department of Education (U.S. Department of

Education, 2001) stated that Federal support for education, excluding estimated Federal

tax expenditures, was over $128 billion in FY 2001. The report further pointed out that

Federal support for education increased 56% between FY 1990 and FY 2001. Of the

estimated $678 billion in direct expenditures by schools and colleges in FY 2001, over

$77 billion was in the form of revenues from Federal sources.

The 1992 reauthorization of the Higher Education Act dramatically changed the

landscape of student financial aid and debt burden. Choy and Li (2005) described

dramatic increases in Federal borrowing due to the increased loan limits and eligibility

for Stafford loans and the introduction of the unsubsidized Stafford loan. They assert that

after adjusting for inflation, the Federal loan volume increased 137% in the decade

following the reauthorization. The amendment also increased family income eligibility

limits for Pell Grants. Part-time students became eligible as well (Prisco et al., 2002).

1993 saw the Student Loan Reform Act dramatically expand the direct loan

program from 100 to 1000 institutions. During the same year, the National Service Trust

Act created "Americorps" and established a national service trust offering individual

grants of nearly $5,000 annually for college costs in exchange for each year of full-time

community service (Prisco et al., 2002).

Choy and Li (2005) also pointed out that the percentage of bachelor's degree

recipients who had borrowed money from any source to finance their undergraduate

education increased from 49% in 1992 to 65% in 2000. Graduate student borrowing









increased from 67% to 72% for dependent students during the same period. More

important, they concluded that higher salaries, low interest rates, and loan consolidation

programs resulted in increased overall debt without substantially increasing the debt

burden (monthly loan payment as a percentage of monthly income).

Zuckman (1991) added that students received fewer grants in the 1980s and into the

1990s. He reported in Congressional Quarterly Weekly that 80% of all Federal financial

assistance in 1975 came from grants. By the early 1990s that figure had dropped to 49%.

President Clinton (1997) began his second term with a State of the Union Address

that declared educational reform his top priority. As a result, the 1997 Taxpayer Relief

Act called for an increase in Federal grants to low-income undergraduates (Kane, 1997)

and $38.4 billion in education tax cuts over 5 years. This included the HOPE Scholarship

tax credit, a Lifelong Learning Credit, and elimination of penalties for IRA withdrawal if

funds were used for postsecondary education. Many argued that these tax credits

benefited primarily middle-income students at higher priced institutions and neglected

lower-income students (Prisco et al., 2002).

Similarly, Thomas Kane (1997), who estimated the cost at approximately $48

billion over 5 years, asserted that the tax cuts were poorly targeted and could be abused

for leisure-oriented coursework. He also claimed that the plan would do little to reduce

the cost to families of future tuition increases. He recommended greater reliance on

income-contingent loan forgiveness as an alternative way to help families pay for college.

Since the Land Grant Acts and the GI Bill, the Federal role in higher education

support has greatly expanded. By increasingly manipulating the terms under which









Federal resources were made available, the Federal government developed substantial

influence over higher education behaviors and outcomes.

Federal Support for Medical Education

Medical training in the United States evolved from an endeavor largely funded by

tuition, fees, endowments, and appropriations to one supported by research grants,

contracts, and clinical practice (Abrahamson, 2000). As funding sources and priorities

changed, the activities of medical students and the roles of faculty changed.

In the 19th century and through the first 10 years of the 20th century, medical

education was very poorly funded. According to Shyrock (1947), theological schools

received $18 million in total endowments. Medical schools received only half a million.

In the years following Abraham Flexner's grilling review of medical education in

the United States, medical schools began to receive hundreds of millions of dollars. Many

of these funds came from national foundations such as the Carnegie Corporation and the

General Education Board. These were added to already generous contributions from

private philanthropists (Ludmerer, 1999).

Following World War I medical schools grew enormously. This growth was partly

fueled by advances in medical research. Research evolved from an activity whose

purpose was to enhance teaching to one that promised to solve the medical problems of

the world. During the 20th Century, the number of medical discoveries in France,

Britain, and Germany began to decline, but the United States experienced dramatic

research breakthroughs in a number of fields. While some U.S. medical schools

generated modest funds from faculty practice, research was clearly at the forefront of

means for generating revenue in U.S. medical schools.









When Medicare and Medicaid legislation was enacted in 1965, the emphasis for

revenue sources slowly began to shift from research to medical service. For instance, in

the early 1960s, every dollar generated from medical service was matched by 4.7 dollars

from medical research. By the late 1970s, the ratio had become 1:1 and by the early

1990s U.S. medical schools received two dollars of revenue from clinical practice for

every one dollar from research (Ludmerer, 1999). Clinical practice was clearly becoming

the cash cow for medical schools.

Federal Funding of PA and NP Training

Non-physician clinician training programs experienced a different history of

financial support. These programs were almost exclusively dedicated to education with a

small amount of faculty practice activity. Since their inception in the late 1960s, the nurse

practitioner and physician assistant professions gained great momentum and support from

Federal programs aimed at improving access to medical care for underserved populations.

While many of their respective training programs were conceived primarily with "soft

money" from grants, the duration of these sources of funding was usually limited; schools

were pressed to find more durable streams of revenue in the future.

Title VII of the Public Health Service Act authorized competitive grants for the

training of physicians, physician assistants, dentists, and other health professionals. Title

VIII programs supported nursing education. Under these titles, the Bureau of Health

Professions (BHPR) administered about 40 grant programs.

In fiscal year 2001, Title VII programs allocated $4.0 million to accredited schools

to meet the costs of planning, developing, and maintaining programs to train physician

assistants in primary care medicine. In the same year, Title VIII programs appropriated

$59 million to support accredited programs in advanced nursing education, including









master's degree programs, post-masters certificate programs and nurse midwifery

certificate programs (Medicare Payment Advisory Commission, 2001).

The National Health Service Corps Scholarship Program

The National Health Service Corps was originally enacted by the Emergency

Health Personnel Act of 1970 to respond to the geographic maldistribution of primary

health care professionals. The program, authorized under Title III of the Public Health

Service Act, was comprised of scholarship and loan repayment programs that provided

education and financial assistance to students in the health professions. In return, the

graduates served in HPSAs for a period of up to 4 years. By placing health professionals

in medically underserved areas, the NHSC played a critical role in providing medical care

to populations that would otherwise have had no access to health care services.

The scholarship program was created in 1972 and the loan repayment program was

initiated in 1987. The NHSC scholarship was created to provide financial support to

health professions students in return for service in designated areas. Similarly, the loan

repayment program repaid both governmental and private loan obligations in exchange

for service. In 1987, Congress also established a State Loan Repayment program. Under

this program, if a state established a loan repayment program similar to the NHSC

program, the Department could fund up to 75% of the total costs through a grant to the

State (U.S. Congress, 2001).

The NHSC Revitalization Amendments of 1990 extended the program for 10 more

years and increased the use of nurse practitioners and physician assistants. In FY 2003

the NHSC made 1204 new loan repayment contracts and 147 new scholarship awards;

they also continued 78 scholarships from the previous year. FY 2004 saw $124 million in

appropriations for NHSC loan repayment and scholarships. President Bush's FY 2005









budget proposal called for a 21% increase to $159 million (Association of American

Medical Colleges [AAMC], 2004).

NHSC Scholarship Program Description. Congress mandated the NHSC to

supply health care professionals with the necessary training and skills to deliver quality

health care services to HPSA populations with the greatest need. The scholarship

program provided the NHSC with graduates from qualified training programs who were

capable of providing health care services to HPSAs throughout the United States.

The program was not a general financial assistance program for students in

health-related professions; rather it was a competitive Federal program, which awarded

scholarships to students pursuing primary care health professions training. The

scholarship provided payment of tuition, fees, and other reasonable costs as determined

by the school. The scholars also received a monthly stipend of $1,065 (DHHS, 2003).

Kirshstein, Berger, Benatar, and Rhodes argued that even though these types of

programs were labeled as "scholarship programs"; they could be more accurately

described as Workforce Contingent Financial Aid (WCFA) programs because recipients

were required to repay the money if they failed to meet the workforce requirements. The

authors described the critical elements of WCFA programs as (1) support to cover

educational expenses either during or after schooling in exchange for (2) a workforce

commitment as a condition for receiving assistance (American Institutes for Research,

2004).

Scholarship programs, on the other hand, award funds for the support of education

with no requirement for repayment or workforce commitment.









Student Eligibility. In order to be eligible for NHSC scholarship awards,

applicants were required to meet a number of requirements. According to DHHS, (2003)

they must have been U.S. citizens or nationals and enrolled or accepted for enrollment as

full-time students in an eligible, accredited training program. Training programs must

have resulted in the appropriate certification and/or licensure as defined by the DHHS.

While most scholarship recipients served their commitments as salaried non-

Federal employees of public or private entities approved by the NHSC, there were

occasional vacancies which required Federal employment. Therefore applicants were

required to be eligible to hold appointments as commissioned officers in the Public

Health Service (PHS) or as Federal civil servants. Additionally, applicants were required

to be free of Federal judgment liens and delinquent debts. They were also required to be

free of other conflicting service commitments (DHHS, 2003).

The scholarship program selection process was very competitive. A number of

factors were considered when selecting applicants. Potential scholars were required to

demonstrate geographic flexibility and a strong interest in providing primary health care

to the underserved populations nationally. First priority was given to previous scholarship

recipients and medical students who were recipients of the Federal Scholarship Program

for Students of Exceptional Financial Need (EFN).

The second priority was given to applicants who demonstrated characteristics that

increased the probability they would continue to practice in HPSAs after they completed

their service commitments. These characteristics included experience with indigent or

underserved communities, intent to participate in pre-professional clinical experiences in









rural or urban community-based health care facilities serving HPSAs, and strong primary

care post-service career goals in HPSAs.

A third priority was given to applicants from disadvantaged backgrounds. These

applicants demonstrated the HPSA retention characteristics and also were certified as

having come from "disadvantaged backgrounds" (DHHS, 2003).

Training Program Requirements. Nurse practitioner training programs were

required to be accredited by one of several listed accrediting bodies and must have

awarded either a Master's degree or a Post-Master's Certificate. Physician assistant

training programs were required to be accredited by the Accreditation Review

Commission on the Education of Physician Assistants (ARC-PA). PA applicants were to

have graduated from a 4-year baccalaureate PA training program or a 2-year post-

baccalaureate program with a Bachelor's or Master's degree. Applicants graduating from

a certificate program or Associate degree program were also required to demonstrate

broad background knowledge of the medical environment, practices and procedures. In

lieu of this knowledge, they were required to provide proof of 3 or more years of

responsive and progressive health care experience as a corpsman, medical technician or

other health care worker. Programs must also have led to national certification as family

nurse practitioners or as physician assistants (DHHS, 2003).

Student Application Process. Applicants were required to submit applications

along with supporting documents several months in advance. Application deadlines were

usually in late March and award notifications complete by the end of September of the

same year. The applicants submitted a signed contract and verification of acceptance or

of good standing from an eligible training institution. Applications of eligible individuals









were scored numerically. If the application fell within a competitive range, he or she was

invited to a personal interview (DHHS, 2003).

The NHSC scholarship program enjoyed a high level of interest among potential

recipients. In a March 2000 testimony before a Senate Subcommittee on Public Health

and Safety, Heinrich (USGAO, 2000) pointed out that the program had almost seven

applicants for every available scholarship.

Scholarship Benefits to Student. Scholarship benefit availability depended on

funding appropriated by Congress for the current year. The scholarship award consisted

of payments, in whole or in part, for tuition, an amount for all other reasonable expenses

incurred by the student and a monthly stipend for the 12-month period beginning with the

first month of each school year in which the applicant was a participant in the scholarship

program. Scholarship support was limited to a maximum of 4 school years (NHSC,

2004a).

Payments for Other Reasonable Costs (ORC) were based on cost estimates

submitted by the scholar's educational institution. These funds covered the costs of

required books, clinical supplies, lab expenses, instruments, two sets of uniforms,

graduation fees, computer/PDA purchase or rental (if required of all students), and travel

expenses for one clinical rotation. A taxable stipend of $1,065 was also provided for each

month of scholarship support (DHHS, 2003).

Scholars were also eligible to receive travel support for pre-employment interviews

at eligible sites. Travel support was authorized up to a total of $1,100 in accordance with

Federal Travel Regulations and NHSC travel policies.









Upon placement, scholars were provided with support for relocation. This included

reimbursement of travel expenses, shipment of household goods up to 18,000 pounds and

storage of household goods for a maximum period of 90 days (NHSC, 2002).

Repayment through service. In return for financial support, the scholars were

required to fulfill their service commitment at HPSA locations in the United States and its

territories. Students agreed to provide 1 year of service for each school year or partial

school year of scholarship support received (DHHS, 2003). Scholars were required to

engage in a full-time clinical practice, defined as a minimum of 40 hours per week for at

least 45 weeks per year, not including on-call or teaching activities. The minimum

service commitment was 2 years and the maximum was 4 years (NHSC, 2002).

The scholars fulfilled the service commitment as non-federal employees,

commissioned officers of the U.S. Public Health Service, or as civilian employees of the

U.S. Government. About 92% of scholars served as non-federal employees of public or

private entities. Scholars provided full-time clinical primary health care services in high-

need, high-priority HPSAs selected by the Secretary of DHHS. The scholars were

provided with a list of eligible sites approximately 4 months prior to the scheduled start

of service. The Early Decision Alternative (EDA) option allowed scholars to compete for

their choice of job vacancies on the list. Recipients who failed to obtain placement in one

of the approved practices by the deadline announced by the NHSC were involuntarily

assigned to a practice based on the needs of the NHSC (DHHS, 2003).

Several types of placement sites appeared on the HPSA list. These included Non-

Federal placements such as Private Practice Assignments (PPAs), which were public or

private entities that operated a community-based system of care, and Private Practice









Options (PPOs), which were private practices that provided fee-for-service or salaried

positions at public, private non-profit, or for-profit sites. Federal placements included

positions with the Indian Health Service (IHS), the Federal Bureau of Prisons (BOP), or

the division of Immigration Health Services of the Immigration and Naturalization

Service (INS). Governing Statutes allowed the NHSC to provide a ratio of up to three

potential practice positions for each scholar up to a maximum of 500 positions (DHHS,

2003). While this may seem to be a generous number of potential employers from which

each scholar may choose, the truth is that this same list of employers was shared by loan

repayment recipients and anyone else that desires to work in a HPSA.

Persistence, Employment and Default. Default, the failure of a scholarship

recipient to provide services as defined in the scholarship contract, resulted in severe

penalties. If a recipient was found to be in breach of contract, the United States was

entitled to recover damages equal to 3 times the scholarship award plus interest in

accordance with the formula:



A = 3 (t-s)
t

Where 'A' = the amount the U.S. is entitled to recover; '4' is the sum of the

amounts paid to or on behalf of the participant and the interest on such amounts which

would be payable if, at the time the amounts were paid, they were loans bearing interest

at the maximum legal prevailing rate as determined by the Treasurer of the United States;

't' is the total number of months in the participant's obligated period of service; and 's' is









the number of months of the period of obligated service served by the participant. This

was all to be paid within 1 year of the date of default (DHHS, 2003).

Challenges to this policy enjoyed little success. An analysis by Helms and Helms

(1991) examined 110 cited judicial decisions from 1950 to 1989 involving medical

students and undergraduate medical education. Disputes over financing medical

education were involved in 54% of these cases. These primarily arose from challenges to

NHSC obligations and from attempts to reorganize or discharge debt under the

Bankruptcy Code. The authors pointed to a need for informed counseling for medical

students, particularly the default consequences of NHSC service obligations and of

incurring loans under the Health Education Assistance Loan (HEAL) program as opposed

to other loan sources.

According to the Department of Health and Human Services, each year a number of

NHSC scholars defaulted on their contractual agreements. Between January 1st, 1999,

and August 18th, 2004, approximately 120 physicians did not fulfill their obligation.

Among nurse practitioners, 27 were in default. Of the approximately 50 nurse practitioner

scholarships awarded per year, 4.5 scholars, or 9%, failed to fulfill their obligation.

Physician assistants were less compliant. During the same 6-year period, 42 scholars

defaulted. This was roughly seven per year or 14% of scholars (DHHS, 2004).

Cullen, Hart, Whitcomb, and Rosenblatt (1997) examined the December 1991

American Medical Association (AMA) master file to determine the practice locations and

specialties of 2903 NHSC physician scholars who graduated from medical school from

1975 to 1983. They found that 20% of the physicians assigned to rural areas were still

located in the county of their initial assignment. An additional 20% were in some other









rural location in 1991. The master file also indicated that 20% of all students graduating

from medical schools between 1975 and 1983 who were currently practicing in rural

counties with small urbanized populations were initially NHSC scholars. A 2004

assessment report by the Office of Management and Budget (OMB) stated that in 2000,

the long-term retention of up to 15 years of NHSC providers after the required service

was 52% (U.S. Congress, 2004).

But NHSC physicians may have demonstrated less dedication to service in HPSAs

than non-NHSC physicians. A study by Pathman, Konrad, and Ricketts (1992) which

contrasted the retention of NHSC and non-NHSC physicians serving in rural settings

between 1981 and 1990, demonstrated that fewer NHSC physicians than non-NHSC

physicians remained in their index practices (12% versus 39%), their index communities

(29% versus 52%), or even in any rural county. Characteristics leading to long-term

retention received much attention at the Federal level in recent years.

NHSC Loan recipients may also have been more likely than scholars to continue

practicing in an underserved community after completing their initial service obligation.

In testimony before the Senate Subcommittee on Public Health and Safety, Heinrich

(USGAO, 2000) referred to an analysis of data for calendar years 1991 through 1993

indicating that 48% of loan repayment recipients were still at the same site 1 year after

fulfilling their obligation compared to 27% of scholarship recipients. She suggested that

this finding may be a result of the timing of the commitment by the recipient. Loan

repayment recipients did not commit to service until after they have completed training.

Therefore, they were more likely to know what they wanted to do and where they wanted

to practice at the time they made the commitment.









While the findings of the Heinrich report merit consideration, these findings were

based on anecdotal evidence drawn from a small sample of years. The NHSC did not

have a comprehensive tracking system in place and did not consider the quality of life or

the specific medical needs at the HPSAs. In an effort to direct scholarship recipients to

the neediest sites, for instance, they were provided fewer choices of where they could

fulfill their service obligation. Heinrich (USGAO, 2000) pointed to more anecdotal

evidence suggesting no significant difference between service sites for scholars and loan

repayers. Finally, the report raises an important point that the NHSC could make more

efficient use of allocated funds.

Few, if any, studies have examined the retention rates of NHSC non-physician

clinicians and non-NHSC NPCs in these settings. Debt levels were generally lower and

service obligation times were shorter for non-physician clinicians. The mean obligation

time for participants in this study was 2.2 years compared to approximately 4 years for

physicians. Demographic differences such as age, marital status and family size may also

have influenced NPCs differently than physicians. Further, amounts of income foregone

during the service period may have been significantly different for physician assistants

and nurse practitioners than for physicians, due to the shorter training period.

There was an inherent expectation that the NHSC scholarship program was a good

investment in that it provided a benefit to society. But, given the dearth of studies

demonstrating any estimate of financial return, perhaps it was the program's potential to

create political capital that allowed it to continue from year to year.

Accountability and Workforce Contingent Financial Aid Programs

Perhaps it was time for the NHSC to revisit the conceptual ideas and methodology

involved in the creation, formulation, and distribution of scholarship funds. More









important, the comparison of scholarship funds invested to health care needs met should

have been more objectively considered.

A 2004 report by the American Institutes for Research examined 161 workforce

contingent financial aid programs in 43 states. Three fourths of these programs were "in-

school" programs that provided financial aid to students while they were enrolled in

school in exchange for a future workforce commitment. The remainders were loan

repayment programs. Participation data were provided by 100 of the programs citing

23,000 individuals receiving support during the 2001-2002 academic year. Only 50 of the

programs studied were able to provide data about how many students fulfilled their work

commitment. The report questioned the effectiveness of the programs and expressed the

need for closer monitoring and evaluation (American Institutes for Research, 2004).

Peter Schmidt (2004) described the report as providing little data to answer

questions such as:

1. Did these programs help reduce labor shortages?

2. How well did the programs cover educational expenses?

3. How many participants drop out of the programs before fulfilling their work

obligations?

4. Did these programs attract people who otherwise might not have entered the

occupations or specialties covered?

Schmidt (2004) cited other concerns raised by the report. He contended that such

programs may actually have caused harm because they provided "psychological and

political cover" for college officials and State lawmakers seeking to raise tuition. He

speculated that the programs made it easier to pretend that tuition increases didn't hurt









real priorities like getting people into the teaching work force. Despite the costs, loan

forgiveness and service-obligated programs may have been one of the only effective

methods to provide medically underserved populations with adequate primary health care

services.

While numerous programs existed for funding the training of health care providers

for service in underserved areas, the Federal government lacked an efficient and

comprehensive system to measure outcomes and alleviate severe shortages. Many of the

problems stemmed from the process used to assign providers to service areas. Other

problems were the result of faulty reporting requirements and unreliable methods for

identification and staffing of the areas with the most critical needs.

In testimony before the Congressional Subcommittee on Public Health and Safety,

Janet Heinrich (USGAO, 2000) listed a number of ways that programs providing health

care access to underserved populations could have been improved. Among her

recommendations, she stated that more dollars should be shifted from NHSC scholarship

programs to loan repayment programs. Among the reasons for a change in priorities, she

explains that (1) the loan repayment programs cost less, (2) loan repayment recipients

were more likely to complete their service obligations, and (3) loan repayment recipients

were more likely to continue practicing in underserved communities after completing

their obligation.

She also stressed a need for an improved system for identifying the need for health

care services in a community. Heinrich further explained that HHS processes for

determining HPSA designation were flawed in a number of ways. For example, non-

physician providers such as physician assistants and nurse practitioners as well as NHSC









providers already practicing in the shortage area were not routinely counted. As a result,

the system tended to overstate the need for more providers.

In a related issue, she asserted that the current system for placement of providers

was severely flawed. She cited a 1993 analysis which found that at least 22% of shortage

areas that received NHSC providers received more providers than needed to increase

their provider-to-population ratio to the point that their HPSA designation could have

been removed. Meanwhile, 65% of shortage areas with Corps-approved vacancies

remained unfilled. Of these vacancies, 143 locations remained unfilled for at least 3

years.

Heinrich also recommended the reevaluation of J-1 visa waivers for physicians who

had just completed their graduate medical education in the United States. In exchange for

service in specified areas, the requirement for these new physicians to return to their

home country could be waived. She contended that in 1999, the number of waiver

physicians was large enough to meet the needs of over one third of HPSA designated

sites nationwide. She concluded by describing the domestic placement effort as

"rudderless" and without accountability (USGAO, 2000).

Human Capital Theory

Investment in human capital is as old as learning itself. Certainly, even the most

primitive societies understood that teaching skills such as hunting, fishing and foraging

would result in an increase in benefits to the group or tribe. Medieval blacksmiths

invested time and effort to train apprentices with the expectation that the increased

productivity would accrue benefits to the business.

But it was not until the 20th century that human capital became a theoretical and

empirical focus of the study of economics. In the 1930's Eugene Gorseline examined









185 pairs of brothers who had differing levels of education within each pair. After

controlling for intelligence, gender, region of the country, time, and family

characteristics, he found that schooling had a significantly positive effect on income. He

did, however, describe a sorting effect and asserted that ability plays a large part in the

decision to further educate oneself (Langelett, 2002).

In the early 1960s Theodore Schultz studied education as a method of building

human capital. He examined the fundamentals of education both as an investment and as

an institution (Schultz, 1963). Building on the work of Shultz, Becker (1964) developed a

broader theory of human capital. As Becker pointed out, countries that enjoy consistent

per capital GDP growth have simultaneously devoted substantial resources to the

development of human capital through nationwide education.

According to human capital theory, any type of education is an investment made by

both the individual and the society or organization that devoted resources to it. Decisions

on the amount of time, money and other resources to invest are based on expectations of

private returns for the individual and social returns for the organizations and/or

governments. Education, as an investment, has been shown to increase personal

productivity and income. Langelett (2002) stated:

Human capital is the "know how" of the work force that increases the
productivity of each worker. The theory of human capital is that investments
can be made in human beings as well as in physical capital, which yield a
future stream of returns or dividends to the initial investment. Investment in
human capital has been one of the major sources of growth in modern
economies during the past century. The process of investing in human
capital normally takes a much longer time period than physical capital. Most
often it takes approximately eighteen years of formal education. In addition,
there are shorter investments in human capital over the lifetime of the
individual that can include additional formal education, on-the-job training,
informal education, life experiences, and learning by doing. ( p.1).









As a social investment, education and training have resulted in a more productive

workforce and growth of the Gross Domestic Product (GDP) (Psacharopolous, 1984).

Critics argued, however, that education may simply function to screen out individuals

with higher innate ability or characteristics that make employees more productive.

Perhaps education serves as one of many mechanisms which sort individuals by their

abilities and labels those abilities with educational credentials. Certainly, innate ability

may directly impact one's productivity. Similarly, ability can help a student maximize

educational opportunity. Belfield (2000) described the "alpha factor" as the so-called

element of the returns to education which is a function of prior ability which may absorb

between 40-80% of any earnings premium. In addition to screening and innate ability,

one must consider factors such as deterioration of education during the years following

commencement, gains made from job experience and opportunities, or lack thereof,

resulting from job performance.

Belfield (2000) also described the "sheepskin effect" as an increase in earnings

solely as a result of a credential attained. For instance, a promotion may be awarded

simply as a result of a person's academic degree attainment. The "sheepskin effect"

implies that the awarding of a credential serves as a signal, and that non-credentialed

years of education produce smaller returns. Belman and Heywood (1997) acknowledged

the importance of the "sheepskin effect", but demonstrated that as workers age and

become more experienced the credential holds less significance. Perhaps the most

powerful signal produced by the credential was when it became a screening tool for

employers planning to hire young, new employees with limited experience and few

references.









Grubb (1993) attempted to demonstrate evidence of the sheepskin effect in a paper

that estimated the returns of postsecondary education using the National Longitudinal

Survey of the Class of 1972 with earnings measured at about age 32. He found that most

of the individuals who enrolled in postsecondary programs but failed to complete

credentials had no higher earnings than high school graduates.

Kane and Rouse (1995) questioned the empirical support for Grubb's findings.

They contended that several variables were mis-measured and that, when corrected with

reasonable alternatives, showed that those who entered but failed to earn credentials at

community colleges did seem to earn more than similar high school graduates. The

authors showed that both men and women who completed 1 year of community college

without completing a degree earned approximately $900 to $1,000 (1985 dollars) more

per year than high school graduates. While they conceded that the t-statistics were only

marginally significant and did not provide overwhelming evidence of the value of a

community college education without credentials, they used the study to discount any

evidence for "sheepskin" effects.

For health care professionals, credentials are critically important. Without proper

credentials at each level of professional development, health care practitioners would not

be eligible for national certification examinations, licensure and, ultimately, employment

in their field. In fact, attainment of such credentials is clearly the most important

yardstick by which the worthiness and competence of health care professionals is

measured.

Psacharopolous (1979) distinguished a "weak" version from a "strong" version of

the screening hypothesis. In the weak version, the employer pays higher starting wages to









more educated workers because he lacks other information about their potential

productivity. In the strong version, the employer continues to pay higher wages to the

more educated employee even though he has had an opportunity to evaluate their job

performance. He discounted the strong version as irrational, arguing that an employer

will re-evaluate hiring decisions on an ongoing basis and make adjustments accordingly.

Cohn and Geske (1990) pointed out another challenge to the human capital

approach in the dual labor market hypothesis. Proponents of this hypothesis argue that the

human capital approach is only valid for certain segments of the labor force. In the "dual"

theory the labor force is divided into a primary segment consisting of individuals hired

into positions holding promise of economic and job mobility, and a second segment

consisting of workers who were hired into positions where they were not likely to receive

good ladder-type positions no matter how much they've invested in training and

education.

The above concerns should not be viewed as arguments against the human capital

model but as factors which may enhance or dilute the effects of an investment in

education. Gains made from an investment in education could vary widely among the

many disciplines of study. Prior work experience, motivation, and academic preparation

could all play an important role in the acquisition of skills during the education process.

Many forms of employment require the specific skills and funds of knowledge acquired

from training and education. In the case of medical training, for instance, it would be

unthinkable to assume that a person could be productive as a clinician without some form

of investment in education.









The Benefits of Education

Education bestows a number of benefits on an individual. Cohn and Geske (1990)

classified these benefits into "consumption" and "investment" components. Consumption

benefits are those products or services which yield satisfaction or utility in a single period

only. For instance, a certain sense of satisfaction and pleasure may be derived simply

from the activity of learning. In addition, many college students gain certain social and

entertainment benefits from campus life and would certainly prefer that to some of the

alternatives. Investment benefits are those which are expected to yield satisfaction in

future periods. By increasing one's productivity and, thus, one's capacity to earn higher

wages in a free market, education not only contributes to the social product but could

increase future consumption benefits to the individual. Education introduces students to

works of music, literature, and the arts and enables them to comprehend material they

would otherwise not be expected to master. From this they are likely to derive greater

utility from leisure activities.

Benefits to the Individual. Education is, perhaps, the single most important

activity that a person can undertake to improve their economic and social success. In

addition to increasing the capacity to earn income, schooling and training increases one's

productivity and, as such, increases one's chances, in a free market, to obtain higher

wages and increase the contribution to the social product (Cohn & Geske, 1990).

Benefits of education may also be classified as "private" and "social". Edwin Dean

(as cited in Langelett, 2002) pointed out eight ways in which education affects a person's

economic well-being or income:

First, and most directly, it increases one's human capital. The rest of the effects are
indirect effects, but nevertheless they do affect one's income and well being.
Second, there is an inverse relationship between the average level of education and









fertility rates in a cross section of countries. Third, education reduces search time in
labor markets. Fourth, there is a correlation between education and health of the
work force. Fifth, there is a direct relationship between the education level of
children and their parents. More highly educated parents generally value education
more and provide greater opportunities for their children to get a higher level of
education. Sixth, there were consumption effects of education. More highly
educated persons make more informed choices in their consumption patterns.
Seventh, education has an effect on crime, social cohesion, and technology
development. Regions with more educated citizens have more social cohesion and
less crime, ceterisparibus. Finally, there are income distribution effects that affect
average income. (p. 11)

Some benefits may belong to both domains. Social benefits include tax payments

associated with the increased income stream and other external benefits that the

individual cannot capture (Cohn & Geske, 1990).

Benefits to Society. Schultz (as cited in Langelett, 2002) identified a number of

ways investments in education benefit not only the individual but the economy as a

whole. First, education changes people's images of themselves and of their society

around them. It empowers them to question the status quo and build better lives for

themselves and for those around them. Second, education empowers us to become better

stewards of scarce resources while developing new ways to create alternate, and

sometimes renewable, resources. Third, education improves the health and increases life

expectancies of individuals and societies as a whole. Fourth, the business of education

and the funds used to attend schools make a net contribution to overall economic growth.

Fifth, research done at colleges and universities often leads to new products and more

efficient ways of producing existing products. Gains in practical commercial research

may also be enhanced as a result of research done at institutions of higher learning. Sixth,

educational institutions nurture, discover, and cultivate talent. By raising the efficiency of

the workforce and improving productivity, education enhances physical capital and raises

GDP. Educated workers are better able to choose fields that best utilize their interests,









talents and ability. Seventh, education enhances people's ability to adapt to change. The

capability to adjust to changes in job requirements and opportunities results in higher

incomes and increased gross domestic product. Eighth, the education system is flexible

enough to expand as demand increases for training required to fill high paying jobs and to

meet the country's needs for people with specific skills and knowledge. Finally,

education increases the labor force participation rate of women and minorities. In

developing countries participation in education reduced fertility rates of women as well.

Many professionals, such as health care providers, provide a social benefit through

activities that improve the health and productivity of the community they serve. Some

health care professionals use their education to produce professional literature for the

benefit of their peers and the health care industry as a whole (Cohn & Geske, 1990).

Fiscal Returns

It was important to determine the relevance of the NHSC scholarship to rewards

and compensation in order to gain an understanding of the benefits to society and to the

individual. A number of methods may be used to estimate such benefits and returns.

Fiscal Returns to the Individual. In The Economic Value of Higher Education,

Leslie and Brinkman (1988, p.39) immediately conceded that "...in conventional

scientific and quantitative terms we were incapable of proving higher education to be

worthy of any particular amount of public support." They go on to explain that the three

major ways to estimate monetary yields of a college education were (1) earnings

differential, (2) net present value (NPV) approach, and (3) internal rate of return (IRR).

All have limitations that preclude any accurate application to education policy decisions.

Yet most estimates of return on educational investment seemed to imply that the

margin of the value of higher education over that of most alternatives was great enough









to justify the expenditures. In 1980 the earnings differential for college graduates (men

and women) compared to high school graduates was 58% higher (Leslie & Brinkman,

1988).

Cohn and Geske (1986) used 1976 census data to show that NPV earnings

estimates at a 5% discount rate reflected a 62% greater benefit than cost for male college

graduates and a 19% greater benefit for females.

Leslie and Brinkman (1988) demonstrated four methods for grouping results of

IRR estimates of college graduates. The mean estimates of the four methods suggested

returns ranging from 11.8 to 13.4%.

It is easy to conclude that by most estimates, investments in education seem to

produce positive returns. But accurate measurements of the intrinsic variables that

contribute to those conclusions remain elusive at best.

Fiscal Returns to Society. In 1961 Theodore Schultz attributed additional

schooling of the labor force for the about one-fifth of the rise in national income between

1929 and 1957 (Schultz, 1961). Over 2 decades later, Denison (1985) explained the 25%

growth in the country's per capital income between 1929 and 1982 by attributing it to a

substantial growth in years of schooling observed during the same time period.

Meanwhile, George Psacharopolous studied relationships between education and

economic growth in a number of countries around the globe. Using methodology

developed by Schultz, he examined private and social returns using education as a proxy

for human capital (Psacharopolous, 1979, 1984, 1985, 1987).









More recently, Robert Barro (1999) found that increased investments in education

in the 1960s were at least partially responsible for the subsequent growth in per capital

income.

Individual and Societal Costs

Cohn and Geske (1990) recognized the importance of earnings foregone by the student

as an important element in total educational cost. These foregone earnings represented a

loss to the student and the unrealized tax revenues, a loss to society. Additionally, health

care professionals, such as nurses, through their work increased the productivity of some

of their patients by getting them back into the workforce sooner. These productivity gains

were lost as the PA or NP student refrained from work to complete their training.

Return Methodologies

Honeyman et al. (1996) described three ways to estimate the monetary yield of a

college education: (1) earnings differentials, (2) the net present value approach, and (3)

private rates of return. There was a continuing lack of consensus among some educators

and economists over which of these was the most appropriate approach and exactly how

returns were to be measured.

Earnings Differential

The earnings differential approach is perhaps the easiest to calculate and most

rudimentary of the three. This measure describes how much more, on average, an

individual earns than other individuals with less education. The earnings differential

approach measures the calculated difference between the average sum of money that

subjects with h years of schooling receive and the average sum received by those with

only h-1 years of schooling using the formula:









n
DIFF = (Wth -Wth 1)
t=0


where Wth is the average earnings, in year t, for subjects with h years of schooling and n

is the number of years worked (Becker, 1992).

Becker (1992) also pointed out that while these calculations are easy to understand

and simple to perform, they are unable to control for costs, discounting, or individual

characteristics. He cautions, however, against dismissing the method too quickly. He

adds that other more sophisticated methods are highly sensitive to changes in costs or

discount rates. He touts the simplicity of this approach as a virtue. Certainly, in more

casual contexts and comparisons, this approach is adequate.

Net Present Value Approach

The net present value approach attempts to estimate the present value of an

education by adjusting costs and benefits to reflect the changing value of a dollar over

time. The result of such analyses is a benefit/cost ratio. Becker (1992) describes the

following formula for calculating the net present value for each year of schooling beyond

h-1 years:



n 0
NPV = (Wth-Wth-1) (1+d)-t (Cth +Wth-1) (l+d)-t
t=1 t=-s


where: Cth is a measure of cost, in year t, for years of schooling h; Wth is a measure of

earnings, in year t for a person with h years of schooling; s is years of schooling

considered, n is a measure of working life; and d is a rate of interest or discount.









For instance, using net present value calculations, Cohn & Geske (1990)

demonstrated that each dollar invested in 4 years of college yielded, on average, $1.19 for

women and $1.62 for men. Interestingly, the authors also showed that postgraduate

education dollars invested yielded $3.05 for women and only $1.00 for men when

compared to the baccalaureate-prepared student.

By discounting dollars to a common year, the NPV approach allows us to compare

investments and returns made in different years. The approach also allows us to consider

costs and foregone earnings.

This method is very sensitive to changes in the discount rate (Becker, 1992).

Because this requires the analyst to made calculations based on their own expectations

about the future of the economy, a large amount of variation can be evident from one

analyst to the next.

Internal Rate of Return

By calculating the discount rate at which the NPV is equal to zero, one may arrive

at the internal rate of return (IRR). This is, perhaps, the most broadly used measure for

estimating the value of an education. By projecting a lifetime stream of earnings and

costs of attendance, the IRR relates total resource costs of education to income benefits

(Honeyman et al., 1996). The utility of the IRR calculation comes from the ability to use

this measure as a means for comparison of different investments. The IRR is, essentially,

a reverse calculation of the NPV. But unlike the net present value calculation, the IRR is

not heavily influenced by the discount rate selection. It is, however, very sensitive to

fluctuations in the cost of the investment (Becker, 1992).

Economists and educators continue to develop new approaches to the problem. In

the 1960s and 70s, for instance, researchers such as Eckaus (as cited in Bowen, 1977),









Becker (as cited in Bowen, 1977), and Mincer (as cited in Bowen, 1977) considered the

impact of ability, occupation and post-college influences on earnings. The importance of

variables such as these depends upon the research question and conditions.

Investment Returns

Positive Production

Several potential indicators of a positive return may be described as acceptable

outcomes of the scholarship program: (1) service in a medically underserved area, (2)

improved community access to health care services, (3) increased productivity of the

community workforce through improved medical care, (4) involvement in community

service activities and organizations, (5) attainment of continuing medical education, (6)

personal advancement through specialized training which required attainment of a

specific degree or license provided by the scholarship program, and (7) continuation in a

postgraduate educational program that would not have otherwise been available without

such a degree.

Negative Production

Several types of investment returns may not be considered to be positive. Some

negative returns include: (1) failure to complete NP or PA school, and (2) failure to

complete service agreement at a designated HPSA site, resulting in default. In these cases

the NHSC recovers a penalty from the scholar equal to three times the amount of

unsatisfied debt from scholarship support. While this penalty may reimburse fiscal losses

to the NHSC, it cannot make up for lost opportunity for other potential scholars.

Other positive or negative investment returns also may have existed. In some cases,

the fiscal return to society may not have been realized through increased tax revenues

generated during the service commitment period. In these cases a scholar's departure






76


from a service site at the end of his or her commitment may still have constituted a

negative return to society.














CHAPTER 3
METHODOLOGY

Research Design

The purpose of this study was to examine the investment return to society and the

individual for the National Health Service Corps (NHSC) scholarship recipients from

physician assistant (PA) and nurse practitioner (NP) programs in the United States who

would have completed service obligations between the years 2003 and 2006. The

problem will be addressed by answering the following questions:

1. Is the difference in the amount of Federal taxes generated between the pre-
and post-training wages sufficient to equal the cost of scholarship awards?

2. How does the social debt ratio factor (the ratio of total scholarship costs to
tax revenue generated during the obligated service period) change the time
required to generate enough Federal taxes sufficient to equal the cost of
scholarship awards?

3. Are there differences in payback potential between nurse practitioners and
physician assistants?

4. Are there differences in foregone earnings during training between nurse
practitioners and physician assistants?

5. Do NHSC PA and NP scholars who complete training receive more or less
income after graduation than before completion of their training program?

To determine the societal investment return, the amount of total scholarship funds

received by each scholar was compared to the total present value of additional taxes paid

over a 35-year period. To determine the individual's investment return, pre- and post-

training wages were compared.

The estimates of additional tax revenues generated from students who received the

NHSC scholarship and a theoretical group of those who did not receive PA or NP









training were determined by comparing post-training wage (scholarship group), and the

expected salaries without the training (no investment group). These two distributions

were used to determine an estimate of the difference in the present value of taxes paid

over a 35-year period. The 35-year career span was determined by adding the average PA

student age of 28 years (AAPA, 2003b) to the training period (2 years) then subtracting

the sum from the customary retirement age (65 years). The estimate of taxes paid each

service year was compared to the total amount of NHSC funds awarded. The study used

annualized pre- and post-training data from scholars who would have completed their

service obligation in 2003, 2004, 2005, and 2006 and compared them to NHSC

scholarship expenses reported by the Department of Health and Human Services (DHHS,

2003, 2004), as well as data from the Bureau of Labor Statistics (Bureau of Labor

Statistics [BLS], 2003), the American Academy of Physician Assistants (AAPA, 2003a,

2003b, 2003c, 2004), and the American Academy of Nurse Practitioners (AANP, 2004).

Participants

Physician assistant and nurse practitioner NHSC scholars with valid mailing

addresses on file at DHHS who would have completed their service obligation between

2003 and 2006 participated in the study. These participants trained at accredited colleges

and universities throughout the United States and repaid their scholarships through

service at Health Profession Shortage Areas (HPSAs) across the nation. While these

colleges and universities may not have been representative of all PA and NP training

sites, the data were adequate for estimating the costs of NHSC scholarships for students

completing PA and NP training as well as estimating the needed payback levels.









Participant Characteristics

Scholars who would have completed service obligations between 2003 and 2006

provided the following data:

1. Pre-training salary

2. Post-training salary

3. Number of dependents claimed on last tax return

4. Pre-training vocation

5. Payback requirement in years

Scholarship costs were estimated using data provided by the DHHS (2004). For

comparison, scholarship costs were calculated as the sum of tuition, stipend and awards

for reasonable expenses.

Payback

Payback was defined as the reimbursement of monetary benefits to society and to

the individual resulting from the scholarship investment. Student incomes before training

as a PA or NP were considered incomes available through "no further investment" in

education.

To determine payback, wages for the "no investment" PA and NP groups were

compared to the "scholarship" groups. For each subject the estimated annual income tax

obligation was determined. Investment return was the difference in the aggregate net

present values of all Federal income tax paid subtracted from the remaining scholarship

debt.

The required number of years of obligated service (service span) was defined for

each subject. For the NHSC "scholarship group", the obligated service span was defined

as the mean number of years required to satisfy the scholarship contract. The projected









number of years to payoff was then calculated for both the "scholarship" and the "no-

investment" groups.

Present Value

The net present value returns the sum of any series of regular cash flows,

discounted to a particular date using a single discount rate. In order to determine the

present value of the wages and scholarship support, the NPV calculation was used to

convert all values to 1997 dollars. This was calculated year-by-year using the applicable

consumer price index reported by the Bureau of Labor Statistics for that year as the

discount rate (BLS, 2005). By converting all values to 1997 dollars subjects can be

treated as if all scholarships started on the same day.

Social Debt Ratio

Debt ratio is considered to be the debt payment over a given period of time divided

by the gross income over the same time period. The social debt ratio, then, is the

monetary value of total scholarship debt to be forgiven during a defined period divided

by the additional tax revenues generated for the same period. Further, the social debt ratio

factor can be derived from the ratio of total scholarship costs to tax revenue generated

during the obligated service period. To obtain the social debt ratio factor the following

formula was used:



Y W
Social Debt Ratio Factor = (Cb+Sb+Hb) / (Rb)
i=1 i=1


where: Cb is a measure of tuition, in year b; Sb is a measure of stipends paid, in year b; Hb

is a measure of other reasonable costs (books, fees, and supplies), in year b; Rb is a









measure of tax revenue generated, in year b; Y is a measure of scholarship years; and W

is a measure of service years. All values were indexed to 1997.

Qualifying Scholars for the Study

There were a number of reasons why some participants were excluded from the

study. Some disqualifying reasons included failure to respond to the survey, breach of

contract, or deferment due to military service. For this study, any scholar who did not

match to a HPSA and begin service was not included. Scholars without valid mailing

addresses on file with DHHS were considered ineligible and were also excluded.

Data Collection Procedures

Subject contact information, scholarship costs, service obligation and other

reimbursement data were obtained through a series of Freedom of Information Act

(FOIA) requests to the National Health Service Corps (DHHS, 2004).

To obtain salary, service obligation, pre-training occupation and dependent

information, a five question survey was developed. Following Institution Review Board

(IRB) approval the surveys were mailed to 421 potential subjects. After a second mailing

107 envelopes were returned marked "undeliverable due to invalid address." Among the

remaining 314 scholarship recipients, nurse practitioners returned 68 surveys. Physician

assistants returned 63%, or 119, of the 187 surveys. This yielded a combined response

rate of 60%.

Treatment of the Data

The present value of wages earned by each individual scholar was used to compute

two different distributions, one to represent expected earnings for "no investment" and

one to represent "scholarship investment" of the study group. The "no investment"

distribution projects wages earned in the absence of the scholarship investment over the









same time period as the "scholarship" group. Similarly, a second distribution was

generated on wages earned after the scholarship investment. Based on the annualized

starting salaries, a "taxes generated" figure was determined by projecting those salaries

through the total service period. Salaries were increased by 3% annually to approximate

customary raises in the industry. This was based on the average changes in total inflation-

adjusted income from primary employers for PAs who stayed in primary care between

the years 1997 and 2003 as reported in the American Academy of Physician Assistants

annual census reports (AAPA, 2003b, 2004) and Nurse Practitioners between the years

1997 and 2001 as reported by the Nurse Practitioner Associates for Continuing Education

annual census report (Pulcini, Vampola, & Ward, 2002).

A special report by the tax foundation (Moody & Hoffman, 2003) was used to

estimate the average Federal tax burden on the American wage earner. The report

estimated the national average effective Federal tax rate for taxpayers in five income

brackets earning between $0 and $292,913. Tax rates ranged from 4.1% to 23.7%. The

effective tax rate was calculated for each year and for each participant based on the

estimated income for that year.

Starting with the reported pre-training salaries, a similar method was used to

calculate foregone earnings of each of the scholars. Mean foregone earnings estimates

were computed for PAs and NPs separately. The mean starting salary for all scholars was

compared to the mean pre-training salary reported by the scholars.









Payback

Societal Payback

The estimated monetary returns to society were determined by comparing the 1997

value of the estimate of taxes paid over a 35-year period of the study group to the 1997

value of the scholarship expenses provided during the training period. Scholarship

expenses were calculated as the sum of tuition payments, stipends and reasonable

expense allowances. Travel and relocation allowances were not considered as part of the

scholarship cost since it is customary for employers to remunerate these costs. To

determine the benefit to society, the differential between pre- and post-training taxes paid

was computed for the study group.

Using a report by Moody and Hoffman (2003), the annual taxes owed were then

calculated based on the income for that year. Taxes were then totaled to determine an

aggregate annual sum. As the projected income increased the tax rate was increased. This

total was compared to a similar aggregate sum for pre-training earnings. The difference

between both sets of tax revenues generated figures is the estimated increase in societal

benefits attributable to the increased wages earned by PA or NP training.

For each service year the total of all taxes paid by each of the scholars was then

subtracted from the balance of scholarship funds awarded for PA or NP training. The

result was the remaining debt owed by the scholar. This procedure was used to calculate

the payback potential for the average scholar and for the scholars found to have the

minimum and maximum social debt ratios.

Individual Payback

Individual payback was measured as increased individual earnings as a result of the

scholar's personal investment in their education. This study examined the difference









between annualized pre- and post- training wages based on survey responses of recent

scholarship recipients. Pre-training wages were used to determine foregone earnings that

scholars would have otherwise received during the training period. A 3% per annum

increase was applied to both distributions. The difference between pre- and post-training

wages projected over the service period minus foregone earnings is the potential payback

to the individual scholar.

Assumptions

The payback to society and to the taxpayer was based on a number of assumptions:

(1) scholars began service in HPSAs immediately after graduation, (2) salaries increased

by 3% each service year and followed the same pattern as the U.S. gross national product

(GNP), (3) students who did not receive scholarships did not have other higher education

opportunities that increased their wages during the service period, and (4) scholars did

not earn wages from a second job or have other sources of income during the service

period.

Comparisons

Income Potential. Annual estimates of earnings for each year were compared

between the "scholarship" group and the "no investment" group. This was projected over

a 35-year period. A 3% annual raise was applied to each group based on reported annual

salaries. All comparisons were made using pre-tax dollars discounted to 1997 values

using the consumer price index.

Social Debt Ratio Factor. The total scholarship cost was divided by the aggregate

tax revenue estimate for the obligated service period for each of the participants. This

resulted in the social debt ratio factor which was then used to determine the scholars with

the maximum and minimum debt ratios. A projection of tax revenue revealed that more









than the 35-year expected career span was required for some of the scholars to pay back

their debt. The projection was extended over a 49 year period in order to more accurately

determine the times to pay back scholarship debt.

Payback Potential. Mean annual estimates of value added tax revenues generated

for each year were projected over a 35-year period for NPs and PAs. A 3% per annum

increase was applied to each scholar's salary and taxes were computed based on the

appropriate income split point. Three components of payback potential: (1) scholarship

costs, (2) social debt ratio, and (3) starting salaries were compared for PAs and NPs using

independent-samples t-tests. The relative magnitude of the difference between means for

each component was estimated using an eta squared calculation.

Foregone Earnings. Foregone earnings were estimated for each of the scholars

based on their reported pre-training income, a 3% per annum salary increase and tax

payments based on the appropriate income split points. The mean foregone earnings

estimates for PAs and NPs were then compared using an independent-samples t-test. The

relative magnitude of the difference between means was estimated using a partial eta

squared calculation.

Effect of Training on Salaries. Mean pre-training and post-training salaries and

were computed separately for NPs and PAs. A split-plot analysis of variance was

conducted to determine which variable (training or discipline) had a greater influence on

salaries and whether there was an interaction effect. The relative magnitude of the

difference between means for training, discipline and interaction effect was estimated

using a partial eta squared calculation.









Effect Size

Calculations of eta squared were done to determine the relative magnitude of the

differences between means. According to Tabachnick & Fidell (as cited in Pallant, 2005)

eta squared represents the proportion of the variance in the independent variable that is

explained by the dependent variable.

The following formula was used to compute eta squared:


Eta squared = t2
t2 + (N1 +N2 2)


where: t is the value derived from the t test; and N is a measure of the size of each

of the samples in the study.

Cohen (as cited in Pallant, 2005) described the following guidelines for the

interpretation of strength of eta squared:

.01 = small effect

.06 = moderate effect

.14 = large effect














CHAPTER 4
RESULTS

The purpose of this study was to examine the investment return to society and the

individual for the National Health Service Corps (NHSC) scholarship recipients from

physician assistant (PA) and nurse practitioner (NP) programs in the United States who

would have completed service obligations between the years 2003 and 2006. One

hundred and eighty seven scholars chose to participate by completing a mail survey.

Other data were obtained from the NHSC through a series of Freedom of Information Act

requests (DHHS, 2004), from the Bureau of Labor Statistics (BLS, 2003), and from

census data provided by the American Academy of Physician Assistants (AAPA, 2003a,

2003b, 2003c, 2004), and the American Academy of Nurse Practitioners (AANP, 2004).

The study examined the following specific research questions:

1. Is the difference in the amount of Federal taxes generated between the pre- and
post-training wages sufficient to equal the cost of scholarship awards?

2. How does the social debt ratio factor (the ratio of total scholarship costs to tax
revenue generated during the obligated service period) change the time required to
generate enough Federal taxes sufficient to equal the cost of scholarship awards?

3. Are there differences in payback potential between nurse practitioners and
physician assistants?

4. Are there differences in foregone earnings during training between nurse
practitioners and physician assistants?

5. Do NHSC PA and NP scholars who complete training receive more or less income
after graduation than before completion of their training program?









Results of the Study

Nurse practitioners and physician assistants who received the NHSC scholarship

participated in this study. Specifically, 421 scholarship recipients who would have

completed their service obligations between the years 2003 and 2006 were initially

selected as the study population. From this population, 187 participants chose to

participate through their response to a mail survey. In each mail survey the participants

indicated the length of service obligation, number of dependents claimed on last tax

return, profession and income received in the year prior to training, and starting salary

immediately after training,

While detailed demographic information was not collected on each of the

participants, there were a number of characteristics that were normally considered when

applicants are interviewed for the scholarship. Specifically, the scholars must

demonstrate geographic mobility and a strong interest in providing health care to

underserved populations. Experience with indigent or underserved communities, intent to

participate in pre-professional clinical experiences in rural or urban community-based

health care facilities and strong primary care post-service career goals in HPSAs were

also important. The NHSC also gave priority to applicants from disadvantaged

backgrounds (DHHS, 2003).

The NHSC provided contact information for each of the scholars and data

pertaining to the amount of scholarship funds invested and years of service obligation.

This information was obtained through the use of a series of Freedom of Information Act

(FOIA) requests (DHHS, 2004). Following appropriate Institutional Review Board (IRB)

approval, short questionnaires (Appendices B and C) were mailed out to scholars on the

mailing list provided by NHSC. The initial mailing yielded 159 responses and 135