Huisartsgeneeskunde: aantrekkingskracht en beroepstrouw ... - Lirias
Huisartsgeneeskunde: aantrekkingskracht en beroepstrouw ... - Lirias
Huisartsgeneeskunde: aantrekkingskracht en beroepstrouw ... - Lirias
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KCE Reports 90 Making G<strong>en</strong>eral Practice Attractive: Encouraging GP attraction and Ret<strong>en</strong>tion 81<br />
Title VII of the Public Health Service Act<br />
The other US federal financial inc<strong>en</strong>tive, Title VII of the Public Health Service Act<br />
(1976), authorizes a myriad of programs for stud<strong>en</strong>ts and institutions to improve the<br />
geographic distribution, quality, and racial and ethnic diversity of the health care<br />
workforce.<br />
Title VII funding of departm<strong>en</strong>ts of family medicine at U.S. medical schools is significantly<br />
associated with expansion of the primary care physician workforce and increased<br />
accessibility to physicians for the population of rural and underserved areas 164 1372 , 165 .<br />
Betwe<strong>en</strong> 1978 and 1993, 2268 Title VII grants were awarded to 120 U.S. medical<br />
schools for family practice predoctoral programs, departm<strong>en</strong>tal support, and faculty<br />
developm<strong>en</strong>t. Grants to departm<strong>en</strong>ts of family medicine in these three programs totaled<br />
$290 million over this 16-year period, with an average annual grant amount per<br />
institution of $127500. In a compreh<strong>en</strong>sive analysis of Title VII funding betwe<strong>en</strong> 1978<br />
and 1993, approximately 180 000 medical school graduates were followed to evaluate<br />
their practice specialty and practice location in the year 2000. Stud<strong>en</strong>ts who att<strong>en</strong>ded<br />
schools that received no family medicine Title VII funding during their four-year t<strong>en</strong>ure<br />
chose family practice at a rate of 10.2 perc<strong>en</strong>t. On the opposite, stud<strong>en</strong>ts who att<strong>en</strong>ded<br />
schools that received that funding for one or more years of their <strong>en</strong>rolm<strong>en</strong>t chose<br />
family practice at a rate of 15.8 perc<strong>en</strong>t. Additionally, Title VII funding was associated<br />
with higher rates of practice in whole county primary care health personnel shortage<br />
areas (1.2 versus 1.5 perc<strong>en</strong>t) and practice in a rural area (9.5 versus 12.7 perc<strong>en</strong>t). A<br />
causal relationship is difficult to ascertain: it is unclear whether some characteristics of<br />
medical schools (e.g. location, stud<strong>en</strong>ts’ population) are associated with receiving Title<br />
VII funds. In their cross-sectional study on GP location in year 2000, Krist et al (2005)<br />
149<br />
show that Title VII funding of medical stud<strong>en</strong>ts as well as medical schools is<br />
associated with an increase in the family physician workforce in rural and low-income<br />
communities, and is temporally related to initiation of funding. Krist et al. 2005 149<br />
observed increases by 2% of the number of GPs in underserved communities, which is,<br />
according to the authors, "a substantial increase as regards access to healthcare".<br />
US state programs offering financial inc<strong>en</strong>tives<br />
Many US state programs 166 furthermore provide financial support to physicians and<br />
midlevel practitioners in exchange for a period of service in underserved areas. These<br />
programs may contribute to the US health care "safety net". Pathman et al (2000) 166<br />
id<strong>en</strong>tified 82 eligible programs operating in 41 states, including 29 loan repaym<strong>en</strong>t<br />
programs (funds to repay educational loans of graduates and practitioners in exchange<br />
for service), 29 scholarship programs (funds to stud<strong>en</strong>ts for tuition, fees and living<br />
exp<strong>en</strong>ses, with expected service after training), 11 loan programs (loans to stud<strong>en</strong>ts for<br />
tuition, fees and living exp<strong>en</strong>ses, with reimbursem<strong>en</strong>t or with exchange for service after<br />
training), 8 direct financial inc<strong>en</strong>tive programs (funds for resid<strong>en</strong>ts and practitioners in<br />
exchange for service), and 5 resid<strong>en</strong>t support programs (funds for resid<strong>en</strong>ts with<br />
expected service after training). The three common features of state programs are a<br />
mission to influ<strong>en</strong>ce the distribution of the health care workforce within the state, an<br />
emphasis on primary care and the reliance on annual state appropriations and other<br />
public funding mechanisms. In 1996, an estimated 1306 physicians and 370 midlevel<br />
practitioners were serving obligations to these state programs, a number comparable<br />
with those in federal programs. The authors conclude that these state programs<br />
constitute a major portion of the US health care safety net.<br />
Pathman et al 2000 166 observed than among physicians who train as GPs, the high costs<br />
of medical education in the USA appear to promote among future GPs national<br />
physician work force goals by prompting participation in service-requiring financial<br />
support programs and perhaps through increasing stud<strong>en</strong>t borrowing. These positive<br />
outcomes for GPs should be weighed against other known and suspected negative<br />
consequ<strong>en</strong>ces of the high costs of training, such as discouraging poor stud<strong>en</strong>ts from<br />
medical careers. Obviously, this is a context-dep<strong>en</strong>d<strong>en</strong>t conclusion.