Outcomes of states' scholarship, loan repayment, and related programs for physicians

Med Care. 2004 Jun;42(6):560-8. doi: 10.1097/01.mlr.0000128003.81622.ef.


Context: Many states attempt to entice young generalist physicians into rural and medically underserved areas with financial support-for-service programs-scholarships, service-option loans, loan repayment, direct financial incentives, and resident support programs-with little documentation of their effectiveness.

Objective: The objective of this study was to assess outcomes of states' support-for-service programs as a group and to compare outcomes of the 5 program types.

Design: We conducted a cross-sectional, primarily descriptive study.

Participants: We studied all 69 state programs operating in 1996 that provided financial support to medical students, residents, and practicing physicians in exchange for a period of service in underserved areas; federally funded initiatives were excluded. We also surveyed 434 generalist physicians who served in 29 of these state programs and a matched comparison group of 723 nonobligated young generalist physicians.

Data collection: Information on eligible programs was collected by telephone, mail questionnaires, and from secondary sources. Obligated and nonobligated physicians were surveyed, with 80.3% and 72.8% response rates, respectively.

Main outcome measures: Levels of socioeconomic need of communities and patients served by physicians, programs' participant service completion and retention rates, and physicians' satisfaction levels.

Results: Compared with young nonobligated generalists, physicians serving obligations to state programs practiced in demonstrably needier areas and cared for more patients insured under Medicaid and uninsured (48.5% vs. 28.5%, P <0.001). Service completion rates were uniformly high for loan repayment, direct incentive, and resident-support programs (93% combined) but lower for student-targeting service-option loan (mean, 44.7%) and scholarship (mean, 66.5%) programs. State-obligated physicians were more satisfied than nonobligated physicians, and 9 of 10 indicated that they would enroll in their programs again. Obligated physicians also remained longer in their practices than nonobligated physicians (P = 0.03), with respective group retention rates of 71% versus 61% at 4 years and 55% versus 52% at 8 years. Retention rates were highest for loan repayment, direct incentive, and loan programs.

Conclusions: States' support-for-service programs bring physicians to needy communities where a strong majority work happily and with at-risk patient populations; half stay over 8 years. Loan repayment and direct financial incentive programs demonstrate the broadest successes.

Publication types

  • Comparative Study
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adult
  • Analysis of Variance
  • Cross-Sectional Studies
  • Fellowships and Scholarships
  • Female
  • Humans
  • Male
  • Medically Underserved Area*
  • Middle Aged
  • Physician Incentive Plans / legislation & jurisprudence*
  • Physicians, Family / economics
  • Physicians, Family / supply & distribution*
  • Primary Health Care
  • Professional Practice Location / economics*
  • Rural Health Services* / economics
  • State Government*
  • Surveys and Questionnaires
  • Training Support / legislation & jurisprudence*
  • United States
  • Workforce