Debt, Repayment Options Influence Physicians' Practice Plans

Diana Mahoney

June 01, 2018

An increasing number of osteopathic medical school graduates intend to practice in medically underserved areas on graduation, and those who leave medical school with the most educational debt are even more likely than their less indebted peers to follow this path, new data show.

The findings contradict the oft-cited theory that heavy burden of school loans might discourage new primary care physicians from serving in poor, rural, and other underserved areas, Jesse R. Richards, DO, from the University of Kansas Medical Center in Kansas City and colleagues report in an article published in the June issue of the Journal of the American Osteopathic Association.

However, an additional finding that those graduates who intend to practice in underserved areas also plan to participate in loan repayment programs might at least partially explain the debt/service intention relationship, as many of these programs require practicing in an underserved location as a loan condition.

The number of colleges of osteopathic medicine in the United States has risen from 20 to 34 in the last decade, during which time enrollment has increased 85%, according to American Osteopathic Association data reported by Medscape Medical News.

During this same period, escalating costs have driven a significant surge in graduates' indebtedness. "Mean osteopathic education debt among 2016 graduates was $240,331, a 16.9% increase from 5 years earlier," Richards and colleagues write. They note that this increase is significantly higher than the 6.7% inflation rate for the same period.

To determine how the growing debt burden affects osteopathic graduates' intention to practice in underserved vs nonunderserved areas, the researchers analyzed data from the American Association of Colleges of Osteopathic Medicine's 2007, 2010, 2013, and 2016 annual graduate surveys.

The mean response rate across the four annual surveys was 76.6%. The percentage of those intending to practice in underserved areas increased significantly from 27.5% in 2007 to 35.3% in 2016, whereas the proportion of graduates who intended to practice in nonunderserved areas decreased from 25.0% to 15.8%.

When analyzed by debt burden, the data showed no statistically significant difference in intention to practice in underserved areas across quartiles of indebtedness in 2007. However, significant differences were observed in 2010, 2013, and 2016. Specifically, graduates with the least debt were significantly less likely than those with the most debt to report their intention to practice in underserved areas, the authors report. For example, in 2016, 30.5% of respondents with the lowest quartile of debt planned to work in an underserved area compared with 43.1% of those with the highest quartile of debt.

Richards and colleagues also analyzed graduates' service intentions based on their plans to enroll in a loan repayment program and determined that in both 2013 and 2016, graduates who planned on practicing in underserved areas were more likely to participate in a loan repayment program than those who planned to practice in nonunderserved areas (68.5% vs 34.9%).

"Although conventional wisdom suggests high debt burdens may drive new physicians away from practicing primary care in underserved areas, this presumption does not seem to be supported by the findings of the current study," the authors write.

"Graduates who intended to practice in underserved areas planned to use loan-repayment programs at much higher rates than graduates who intended to practice in nonunderserved areas. This finding may be confounded by the fact that a large number of loan-repayment programs require underserved area location of practice," the authors state. They note, however, that research to date has not provided clear evidence that loan repayment programs influence practice patterns.

The authors note several study limitations, including that they did not evaluate the association between specialty choice and practice location, nor whether students came from underserved areas. Nonetheless, the findings suggest an important relationship between educational debt, repayment options, and practice location.

"A growing body of evidence suggests that the career paths of osteopathic medical graduates can be shaped by finances and incentives," the authors write.

"The increasing use of programs currently in place to help reduce health care access inequality by attracting physicians to underserved areas seems to provide effective incentives with tens of thousands of dollars a year in student loan repayment."

Continued expansion of loan repayment programs and incentives "may prove critical to placing newly graduated physicians in areas of greatest need," the authors write, noting that more research is needed to develop, support, and manage these programs.

The authors have disclosed no relevant financial relationships.

J Am Osteopath Assoc. 2018;118:384-388. Abstract

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