Larkin Hoffman is providing a four-part series on how the Patient Protection and Affordable Care Act ("PPACA") intends to make changes in the workforces of physicians, nurses, dentists, geriatrics, long-term care, Allied Health, and mental and behavioral health. See July 2010 and August 2010 articles for the first and second articles in the series. This article looks at the efforts of the PPACA to increase the supply and training of physicians, nurses and dentists.

Physician Workforce
The current demand for primary care physicians far exceeds the supply. The PPACA provides incentives through new scholarships and repayment programs to recruit medical students to address the workforce shortages while also focusing on the underserved and rural populations that are in great need of primary care physicians. The PPACA establishes programs to encourage pediatric subspecialists, family medicine, and practice in rural areas.

Increase Supply
The federal student loan program for primary care physicians is modified by the PPACA to encourage doctors to practice in primary health. The changes limit the service obligation in primary health to 10 years (instead of the date when the loan is paid in full), it lowers the penalty for failure to comply with the loan agreement, and parental financial information is no longer required for independent students.

Physicians who agree to work full-time for at least two years in a pediatric specialty, pediatric surgical specialty, or in child and adolescent mental and behavioral health care, will be eligible for a loan repayment program. The specialist would have to work in a medically underserved area or in an area that has a shortage of the specified pediatric specialty. The program will pay up to $35,000 for each year served.

In a further effort to increase the physician supply, the PPACA will re-distribute unfilled residency positions to other qualifying hospitals. A hospital that qualifies for additional residency positions will be required to use those slots for the training of primary care physicians and general surgery.

Training and Education
To encourage training programs in primary care, the Secretary of Health and Human Services can award five year grants or contracts to accredited public or nonprofit hospitals, schools of medicine or osteopathic medicine. Grants are to be used to develop and operate training programs in family medicine, general internal medicine, or general pediatrics for medical students, interns, residents, or practicing physicians.

To address the problem of physician shortages in rural areas, the PPACA authorizes grants to medical schools and other eligible entities who establish programs to recruit and train students likely to work in rural underserved areas. The grant funds would be used to improve and expand on the rural-focused training. $4 million will be appropriated for 2010-2013.

To combat the low levels of health care providers in rural areas, the PPACA also encourages medical residency training in community-based sites including health centers and rural health clinics.

Other Workforce Improvements
 Medicare will pay a bonus of ten percent for 2011 through 2016 to primary care practitioners and general surgeons who practice in health professional shortage areas (HPSAs).

Dental Workforce
Due to a concern by the Health Resources and Services Administration ("HRSA") that there is a lack of general dentists and dental services in disadvantaged populations, the PPACA provides grants for the training of dentists in shortage areas and loan repayment options for dental faculty.

The PPACA expands the grants and contracts available for training of dental students, dental residents, dental hygienists, and dental faculty in the areas of general, pediatric, and public health dentistry. Additionally, grants and contracts will be awarded to help maintain, establish, or improve dental faculty development programs.

Grants for a loan repayment program will also be available to dental faculty in general, pediatric, or public health dentistry programs. The dentistry programs can apply for grants or contracts to develop and operate a loan repayment program under which faculty agree to serve as full-time faculty members.

Additionally, the PPACA authorizes grants to be awarded to eligible entities to create demonstration projects to train and employ alternative dental health care providers. The purpose of the grants are to increase access to dental services in rural and underserved communities.

Nursing Workforce
 There may be a nationwide nurse shortage of up to 260,000 by 2025 according to a 2009 study by Dr. Peter Buerhaus of Vanderbuilt University. In response, the PPACA provides grants for loan incentives, training, and education to help increase the supply of available nurses.

Increasing Supply
The PPACA increases the annual and overall limit of The Nursing Student Loan program. The PPACA provides additional funding to increase the academic year limit to $3,300 up from $2,500, and for the final two years of the program up to $5,200 per student, up from $4,000. The aggregate limit is also increased from $13,000 to $17,000.

The PPACA grants $50 million to support nurse-managed health clinics. Nurse-managed health clinics provide primary care or wellness services to underserved or vulnerable populations. Nurse-managed clinics have been funded through grants awarded by the Secretary of Health and Human Services.

Training and Education
 The PPACA updates and enhances the Public Health Service Act (PHSA) to authorize the Secretary of Health and Human Services to award grants and enter into contracts with an accredited school of nursing, a health care facility, or a partnership of such a school and facility to improve nurse retention, practice, and education. Grants can be awarded for promoting career advancement and to develop and implement internship and residency programs.

The PHSA provides loan repayment to nurses who serve as a nurse for a period of at least two years in a health care facility with a critical shortage of nurses. The PPACA expands the loan repayment program to include nurse faculty at an accredited school.

To increase the number of qualified nursing faculty, a nurse faculty loan program, operated through agreements with nursing schools, will be expanded to add individual educational loan repayment to nurses who serve as faculty. To be eligible, the faculty member must have a master's or doctorate nursing degree and must be a faculty member at an accredited nursing school for a least four years.

Next month, Larkin Hoffman will look at the efforts of the PPACA to increase the supply and training of geriatric and long-term care, public health, Allied Health, and mental and behavioral health workforces.

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