Higher education financial incentives for health professionals serving underserved areas

Evidence Rating  
Some Evidence
Evidence rating: Some Evidence

Strategies with this rating are likely to work, but further research is needed to confirm effects. These strategies have been tested more than once and results trend positive overall.

Health Factors  
Community in Action

Financial incentive programs offer scholarships and loans with service requirements, educational loans with a service option, and loan repayment or forgiveness programs to encourage health care providers to serve in regions that are rural, underserved, or Health Professional Shortage Areas (HPSA). Such incentives are available to various types of providers, including physicians, nurse practitioners, physician assistants, nurses, dentists, and mental health providers, but typically focus on primary care and family medicine practitioners1.

What could this strategy improve?

Expected Benefits

Our evidence rating is based on the likelihood of achieving these outcomes:

  • Increased availability of health professionals in underserved areas

Potential Benefits

Our evidence rating is not based on these outcomes, but these benefits may also be possible:

  • Increased access to care

What does the research say about effectiveness? This strategy is rated some evidence.

There is some evidence that financial incentive programs increase the number of health care providers serving in underserved areas2, 3, 4, 5, 6, 7. Additional evidence is needed to confirm effects and determine which incentives are most effective2, 8.

Participants in financial incentive programs are more likely to serve in underserved areas than non-participating peers3, 7, 9. On average, participants remain in underserved areas longer than non-participants3, 9. However, providers may not always stay in rural or remote communities following their commitment8.

Scholarships, loan repayments8, and loan forgiveness programs appear to support recruitment of health care providers to underserved areas7. Loan repayment programs also appear to increase the duration providers practice in these locations2, 6, 10. Financial incentives are more effective as part of multi-dimensional programs than incentives alone5, 8, and incentive programs offered at the end of training may be more successful than those offered earlier9. Surveys suggest that competitive salaries, professional development, knowledgeable support staff, and professional support may increase the likelihood of provider retention in rural or underserved areas after the completion of service commitments11.

Mid-level providers such as nurse practitioners (NPs), nurse midwives, and physician assistants are more likely to practice in rural areas than other health care professionals7. Primary care NPs12, 13 and family medicine NPs14 are also more likely to practice in rural or underserved areas than NPs with other specialties. Research suggests that providers who participate in financial incentive programs may have elected to practice in underserved areas even without incentives9, 10. In particular, rural background or origin is associated with the decision to practice and remain in rural communities3, 4, 7, 10, 15, 16.

Experts suggest that expanding financial incentives with service requirements to include general surgeons17, 18, OB/GYN physicians, nurse midwives19, and telehealth providers offering mental health care18 may increase access in rural and underserved communities. 

How could this strategy impact health disparities? This strategy is rated likely to decrease disparities.
Implementation Examples

The National Health Service Corps (NHSC) provides up to $50,000 in loan repayment and scholarships for physicians, dentists, advance practice nurses (nurse practitioners, certified nurse midwives), physician assistants, dental hygienists, and mental health professionals who work for two years in a Tier 1 Health Professional Shortage Area (HPSA)20. NHSC’s Students to Service Loan Repayment Program (S2S LRP) also provides up to $120,000 to fourth year medical students who commit to practice primary care in a HPSA for three years full-time or six years half-time21.

A number of other entities provide loan repayment programs. The Health Resources and Services Administration (HRSA), for example, offers a Nursing Education Loan Repayment Program that repays 60% of qualified loan balances for two years of work at a critical shortage facility; for an optional third year, it will pay 25% of the original balance22. The Indian Health Service’s Loan Repayment Program provides $20,000 per year for two years for a variety of providers and allied health professionals; the contract may be extended annually until the debt is paid23.

State funded loan repayment programs may complement the NHSC federal program20, 24. States can also include other specialties in their loan repayment programs, for example, in North Carolina general surgeons practicing in HPSAs are eligible18.

Implementation Resources

RHIhub-Loan forgiveness 2014 - Rural Health Information Hub (RHIhub). Programs for loan repayment and forgiveness: A list for rural providers. The Rural Monitor. 2014.

US DHHS-NHSC - U.S. Department of Health and Human Services (U.S. DHHS). National Health Service Corps (NHSC). Growing the primary care workforce by serving communities.

HRSA-NELRP - Health Resources and Services Administration (HRSA). Nursing education loan repayment program (NELRP). U.S. Department of Health and Human Services (U.S. DHHS).

US DHHS-IHS - U.S. Department of Health and Human Services (U.S. DHHS). Indian Health Service (IHS). IHS Loan repayment program.

RTT Collaborative - RTT Collaborative. Rural education & training: Resources on rural residencies, training tracks, program locations, and financial resources.

ASHA-Student loan repayment - American Speech-Language-Hearing Association (ASHA). The ASHA Leader. Student loan repayment looms for new clinicians. 2015.


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1 Geletko 2014 - Geletko KW, Brooks RG, Hunt A, Beitsch LM. State scholarship and loan forgiveness programs in the United States: Forgotten driver of access to health care in underserved areas. Health. 2014;6(15):1994-2003.

2 Goodfellow 2016 - Goodfellow A, Ulloa JG, Dowling PT, et al. Predictors of primary care physician practice location in underserved urban and rural areas in the United States: A systematic literature review. Academic Medicine. 2016;91(9):1313-1321.

3 Cochrane-Grobler 2015 - Grobler L, Marais BJ, Mabunda S. Interventions for increasing the proportion of health professionals practising in rural and other underserved areas. Cochrane Database of Systematic Reviews. 2015;(6):CD005314.

4 Wilson 2009 - Wilson NW, Couper ID, De Vries E, et al. A critical review of interventions to redress the inequitable distribution of healthcare professionals to rural and remote areas. Rural and Remote Health. 2009;9(2):1060.

5 Sempowski 2004 - Sempowski IP. Effectiveness of financial incentives in exchange for rural and underserviced area return-of-service commitments: Systematic review of the literature. Canadian Journal of Rural Medicine. 2004;9(2):82-88.

6 Opoku 2015 - Opoku ST, Apenteng BA, Lin G, et al. A comparison of the J-1 visa waiver and loan repayment programs in the recruitment and retention of physicians in rural Nebraska. The Journal of Rural Health. 2015;31(3):300-309.

7 Daniels 2007 - Daniels ZM, Vanleit BJ, Skipper BJ, Sanders ML, Rhyne RL. Factors in recruiting and retaining health professionals for rural practice. Journal of Rural Health. 2007;23(1):62-71.

8 Misfeldt 2014 - Misfeldt R, Linder J, Lait J, et al. Incentives for improving human resource outcomes in health care: Overview of reviews. Journal of Health Services Research & Policy. 2014;19(1):52-61.

9 Barnighausen 2009b - Bärnighausen T, Bloom DE. Financial incentives for return of service in underserved areas: A systematic review. BMC Health Services Research. 2009;9:86.

10 Renner 2010 - Renner DM, Westfall JM, Wilroy LA, Ginde AA. The influence of loan repayment on rural healthcare provider recruitment and retention in Colorado. Rural and Remote Health. 2010;10(4):1605.

11 Scarbrough 2016 - Scarbrough AW, Moore M, Shelton SR, Knox RJ. Improving primary care retention in medically underserved areas: What’s a clinic to do? The Health Care Manager. 2016;35(4):368-372.

12 Spetz 2016 - Spetz J, Skillman SM, Andrilla CHA. Nurse practitioner autonomy and satisfaction in rural settings. Medical Care Research and Review. 1077558716629584.

13 DesRoches 2013 - DesRoches CM, Gaudet J, Perloff J, et al. Using Medicare data to assess nurse practitioner-provided care. Nursing Outlook. 2013;61(6):400-407.

14 Odell 2013 - Odell E, Kippenbrock T, Buron W, Narcisse MR. Gaps in the primary care of rural and underserved populations: The impact of nurse practitioners in four Mississippi Delta states. Journal of the American Association of Nurse Practitioners. 2013;25(12):659-666.

15 Crump 2015 - Crump WJ, Fricker RS, Ziegler CH, Wiegman DL. Increasing the rural physician workforce: A potential role for small rural medical school campuses. Journal of Rural Health. 2015;00:1-6.

16 Petrany 2013 - Petrany SM, Gress T. Comparison of academic and practice outcomes of rural and traditional track graduates of a family medicine residency program. Academic Medicine. 2013;88(6):819-823.

17 Tierney 2017 - Tierney J, Terhune K. Expanding the National Health Service Corps scholarship program to general surgery: A proposal to address the national shortage of general surgeons in the United States. JAMA Surgery. 2017;152(4):315-316.

18 Collins 2016 - Collins C. Challenges of recruitment and retention in rural areas. North Carolina Medical Journal. 2016;77(2):99-101.

19 Smulian 2016 - Smulian EA, Zahedi L, Hurvitz J, et al. Obstetric provider trainees in Georgia: Characteristics and attitudes about practice in obstetric provider shortage areas. Maternal and Child Health Journal. 2016;20(7):1341-1348.

20 US DHHS-NHSC - U.S. Department of Health and Human Services (U.S. DHHS). National Health Service Corps (NHSC). Growing the primary care workforce by serving communities.

21 US DHHS-NHSC-S2S LRP - U.S. Department of Health and Human Services (U.S. DHHS), National Health Service Corps (NHSC). Students to Service Loan Repayment Program (S2S LRP).

22 HRSA-NELRP - Health Resources and Services Administration (HRSA). Nursing education loan repayment program (NELRP). U.S. Department of Health and Human Services (U.S. DHHS).

23 US DHHS-IHS - U.S. Department of Health and Human Services (U.S. DHHS). Indian Health Service (IHS). IHS Loan repayment program.

24 Pathman 2012a - Pathman DE, Morgan JC, Konrad TR, Goldberg L. States’ experiences with loan repayment programs for health care professionals in a time of state budget cuts and NHSC expansion. The Journal of Rural Health. 2012;28(4):408-415.

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