Becoming a doctor can be an expensive proposition when you factor in the cost of a four-year undergraduate degree and medical school. U.S. News data shows that for the 2017-2018 academic year, average tuition and fees for undergraduate students enrolled in public, in-state institutions was $9,528. Average tuition jumped to $21,632 for out-of-state students in public institutions, while private institutions charged an average of $34,699 for the year. But multiply those figures by the four years it generally takes to earn a bachelor’s degree and we’re talking about serious money that most 18- to 22-year-olds are unlikely to have on hand. In 2016, 67 percent of students left school with an average total debt of $28,773.
For students pursuing a medical career, the cost burden only escalates. The Association of American Medical Colleges reports that the median four-year cost of attendance for the class of 2018 was $243,902 for public institutions and $322,767 for private institutions. With figures that high, many students finance their educations through student loans. The AAMC reports that 75 percent of all 2017 medical school graduates left school with some educational debt. Their median debt load was a staggering $192,000.
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These eye-popping figures mean that many doctors have to make difficult decisions about what kind of medicine they will practice and where they will do so upon completion of training. Students with massive amounts of debt may forego lower-paying fields like pediatrics and primary care and gravitate toward higher-paying specialty fields and work in urban environments where the standard of living is higher instead of heading to rural or underserved communities where the need for these services is highest. These financial facts aren’t helping to alleviate the inequitable distribution of doctors and other health care providers across the United States.
Getting Doctors to Rural Areas
Some communities are getting creative in how they’re attracting top talent to rural and underserved areas. Consider Vermont, for example. The U.S. Census Bureau reports that Vermont is the most rural state in the nation, with 61.1 percent of its population living in rural areas in 2010. Because the state’s population is so spread out, providing adequate care can be challenging. But a state program to help repay student loans is helping to entice more primary care providers to the state. The Vermont Educational Loan Repayment Program for Health Care Professionals offers loan repayments between $10,000 and $20,00 per year in exchange for a one- to two-year service commitment.
These sorts of programs have become more common around the country, says Georgia J. Maheras, director of Vermont public policy for the Bi-State Primary Care Association, a nonpartisan, nonprofit that enables services and improves access to primary care and preventive health care in Vermont and New Hampshire. “Loan repayment has become standard around the country. Because of the pervasiveness of these programs … it’s become an expectation or a standard for recruitment.” Therefore, keeping this funding flowing is critical to being able to meet the health care needs of the state’s population. But in January, funding for the Vermont loan repayment scheme was earmarked for elimination in the governor’s budget. It has since been restored by both the Vermont House and Senate. Although the budget hasn’t yet been signed into law, Maheras says chances are good that the program will survive. But it’s easy to see that ending this program could have had consequences for the health of Vermont’s population.
Even with the funding, Maheras says it’s important to attract the right physicians to Vermont, and that takes some effort. It all starts with an application from the physician. If an applicant meets eligibility criteria and can fill a need in an area where there’s a shortage, the primary care physician will be awarded funds for loan repayment in exchange for a specified service commitment. The program also recruits nurse practitioners, certified nurse midwives, physician assistants and psychiatrists. Naturally, most health centers will try to retain doctors in the program, so additional local incentives such as bonuses or other compensation may come into play.
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As Maheras notes, staff recruiting is challenging and keeping health care providers on board after their service commitment has ended is a focus for many of the health centers and hospitals in the state, which starts with making a good match. “It feels a little bit like marriage,” she says, with some health centers bringing prospective doctors in to meet the team and explore the neighborhood. Some hospitals and health centers make big efforts to connect the doctor’s spouse or partner with job opportunities, and some candidates may be introduced to local real estate agents and educators to learn about their options for life outside of work.
“It’s very broad,” Maheras says. “I think of it like hugging somebody, wrapping around them all the things that an individual thinks of when they’re moving somewhere new, because this is the overwhelming majority.” Rather than native Vermonters returning home after being trained, more commonly, these doctors are transplants from other parts of the country. “We don’t produce that many primary care doctors in Vermont. We have to attract them from elsewhere.”
Funding for the program “flows through our Area Health Education Center Program, at the University of Vermont Larner College of Medicine,” Maheras says. The program is structured as a combination of state and federal funds. “We try to make the biggest pot we can for this,” and one of the requirements for releasing funding is that the employer matches the award made to the physician. “The individual would get none of the award if the employer or the community doesn’t match it,” she says, which generates buy-in from the health centers where these doctors will serve.
That need for buy-in goes both ways. “For some of these communities, we need clinicians who love it and who are fine with driving over a mountain in the snow,” Maheras says. The goal of the program is, “to the extent that you can, make it financially feasible. Given the amount of debt they’re coming out of school with, every little bit helps.”
Help Needed in Underserved Locations
But rural populations aren’t the only ones that need the services of good doctors. Deep in the heart of one of America’s most densely populated urbanized areas, a traditionally underserved community that has a higher than average need for health care, particularly mental and behavioral health services, often goes without. But that could be changing for inmates in Los Angeles County jails.
Dr. Margarita Pereyda, chief medical officer of the LA County DHS-Correctional Health Services, says the inmate population is a community, “albeit one within closed walls,” and it needs to be served with “a health system just like any other health system.” In the past, it’s been challenging to recruit top doctors to the field of correctional health, so in 2016, the county made some changes to how it was handling inmate care — switching from “episodic care to a more holistic approach that addresses chronic as well as acute needs,” Pereyda says. Making this shift will result in the recruitment of 40 primary care doctors and 76 other health care providers, such as nurse practitioners and physician assistants, to serve a population of about 18,000 inmates housed in three large and two smaller correctional facilities in greater Los Angeles. The county is offering financial incentives to encourage doctors to sign on.
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“People go into medicine for the right reasons, but at the end of the day you’re coming out with a lot of debt,” Pereyda says. And while working at a high-paying boutique practice that has all the latest technology might be appealing for some, there are some doctors — the “Doctors Without Borders” type of person — who might prefer to work with underserved populations but simply can’t because of the financial constraints imposed by their education debts. These are the doctors Pereyda is trying to recruit, by offering competitive salaries and other incentives such as loan repayment. “It’s OK to ask people to be mission-driven. It’s another thing to ask them to live like missionaries. Money isn’t everything, but loan repayment, that’s a huge weight off someone’s shoulders,” she says. The county is also currently funding a fast-track training program in conjunction with California State University, Los Angeles, to elevate registered nurses to nurse practitioners, another way to address the need for health care professionals in the system.
Beyond those recruitment tactics, Pereyda says it’s important to “remove the stigma” around being a prison doctor. Changing the care model is one way to do that, and partnering with academic centers and other practices that can help doctors learn and grow professionally is also helping elevate the concept of correctional health. “I really believe that LA County, being the largest jail in the country, we have a duty to provide excellence in care to our community if they are unfortunate enough to find themselves incarcerated. We also have a duty to help set a best-practice standard.” She says it’s important to change the perception of correctional health as being a place for doctors who “couldn’t get a job anywhere else and this is where you came to hide as a doctor, to a view that is, ‘I chose to go there because I’m into this from a social justice or health equity perspective.'”
Although the program is just launching, the concept is appealing to doctors who have a strong sense of social justice, whether they also have a lot of educational debt or not.
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How Some Communities Are Freeing Doctors From Medical School Debt originally appeared on usnews.com
