Annals of Family Medicine: Papers illustrate ways in which federal and insurance policies may negatively influence primary care practice

ANN ARBOR, Mich., July 25, 2023 /PRNewswire/ -- Two papers published in the July/August issue of Annals of Family Medicine address federal policy impact on Family Medicine practice. The first documents differences in how federal medical school loan repayment programs support doctors who want to practice in rural and underserved areas. The second describes the impact of differences in insurance reimbursement rates for identical care based on specialty and the implications of these differences on patient access to care.

Medical school debt repayment programs' influence on family medicine practice 

With the average medical school debt soaring to $200,000 over the last few decades, the escalating financial burden is driving concerns that medical students may opt out of lower-pay but high-value public service careers in Federally Qualified Health Centers (FQHCs), rural health clinics, and the Indian Health Service. Loan repayment programs — like the Public Service Loan Forgiveness (PSLF) program and the National Health Service Corps (NHSC) — play a vital role in facilitating the entry of aspiring doctors into the healthcare workforce by alleviating the burden of high educational costs.

Researchers from the American Board of Family Medicine (ABFM) and the University of Minnesota Medical School conducted a study to determine how the background of family doctors, particularly those from historically underrepresented groups, influenced their choice of medical school loan repayment programs and how this, in turn,  impacted the care they provide to patients.

By analyzing data from over 10,000 ABFM National Graduate Survey respondents, the authors examined differences in program participation, participant demographics, scope of practice, and the likelihood of serving medically underserved or rural populations. 

The study revealed a significant increase in participation in the PSLF program between 2016 and 2020, while participation in the NHSC program remained static. The authors note that heavily-indebted early career physicians are strongly attracted to PSLF because of the possibility of unlimited forgiveness as a debt mitigation strategy. Since an estimated 68% of health system employers qualify as non-profit for PSLF purposes, the program is broadly available to medical graduates regardless of practice specialty, geographic location, or practice pattern.

Physicians enrolled in the NHSC program were more likely to come from underrepresented groups; exhibited a wider scope of practice; and were more inclined to practice in rural areas (23.29% compared to 10.84% in PSLF). They also were more likely to practice in areas designated as Health Professional Shortage Areas (12.5% compared to 3.70% in PSLF), serving medically underserved populations (82.17% compared to 24.22% in PSLF).

The analysis conducted in this study suggests that PSLF may be less effective in supporting family physicians from underrepresented backgrounds and may also be less helpful in promoting a broader scope of practice or directing physicians to underserved settings compared to service-based loan repayment programs like NHSC. 

"These findings raise the question of whether the PSLF repayment mechanism may provide more support to demographically overrepresented groups than to those who are underrepresented in medicine amidst national calls to increase their inclusion in the physician workforce," the authors write. "In a nation where a disproportionately low share of medical students hail from rural backgrounds and only 7% of physicians identify as Black or Hispanic/Latino, it is critically important to understand the contributions of medical education debt reduction to addressing these equity gaps."

Under-funding family doctors for providing commensurate care

In a second paper, researchers investigated the reimbursement rates for HPV vaccine costs – the costliest of all routinely recommended pediatric vaccines -- among various medical practitioners, including pediatricians, family doctors, internal medicine doctors, and nurse practitioners. The team also examined whether the reimbursement amounts were associated with the number of HPV vaccine doses administered by these healthcare workers. They argue that adequate cost reimbursement by third-party payers is a critical enabling factor for providers to continue offering the HPV vaccine.

The study analyzed 2017-2018 data from 34,247 practitioners and found family physicians had on average the lowest net returns per dose ($0.34) and the lowest reimbursement rate at $211.33, while pediatricians had on average the highest returns ($5.08) and the highest reimbursement rate at $216.07. Average reimbursement rates for internists were $212.97; nurse practitioners at $212.91; and 'other' providers at $213.29.

Despite the low reimbursement rates, family practitioners have the second highest volume of HPV vaccination encounters after pediatricians. This presents financial and operational challenges for family doctors to stock vaccines.

The researchers also observed that a one-dollar increase in return was associated with a slight increase in HPV vaccine doses administered, particularly among family physicians (0.08% per dollar).

"While it may not be possible to increase reimbursement to the American Association of Pediatrics-recommended level ($263.74, i.e., a net return of +$40), a reasonable increase that can cover direct and indirect expenses (acquisition cost, storage cost, personnel cost for monitoring inventory, insurance, wastage, and lost opportunity costs) will reduce the financial strain on non-pediatric providers, encouraging them to stock and offer the HPV vaccine at their clinics," the authors write.

Articles cited:

Service-Based Student Loan Repayment Program Impact on the Primary Care Workforce. Caitlin S. Davis, MD, MSc, Peter Meyers, MD, MPH, Andrew W. Bazemore, MD, MPH, and Lars E. Peterson, MD, PhD

Reimbursement for HPV Vaccine Cost in the Private Sector: A Comparison Across Specialties. Kalyani Sonawane; Yenan Zhu, MS; Yueh-Yun Lin, MS, Ruosha Li, PhD, Cara He, BS; David R Lairson, PhD, Ashish A Deshmukh, PhD, MPH

Annals of Family Medicine is a peer-reviewed, indexed research journal that provides a cross-disciplinary forum for new, evidence-based information affecting the primary care disciplines. Launched in May 2003, Annals is sponsored by seven family medical organizations, including the American Academy of Family Physicians, the American Board of Family Medicine, the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors, the North American Primary Care Research Group, and The College of Family Physicians of Canada. Annals is published online six times annually and contains original research from the clinical, biomedical, social and health services areas, as well as contributions on methodology and theory, selected reviews, essays and editorials. Complete editorial content and interactive discussion groups for each published article can be accessed free of charge on the journal's website, www.AnnFamMed.org.

SOURCE Annals of Family Medicine