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Loan Repayments Help Pharmacists Provide Care in Medically Underserved Areas

Donna Young

The National Health Service Corps (NHSC) in September awarded student loan repayments of up to $50,000 each to 23 pharmacists who have agreed to serve for at least two years in medically underserved communities in the United States and its territories, known as health professional shortage areas (HPSAs).

The program is a demonstration project that will help the Health Resources and Services Administration (HRSA) determine whether the addition of pharmacists as permanent NHSC members would improve patient outcomes at HPSA sites, said Rear Admiral Donald L. Weaver, NHSC director and an assistant surgeon general in the U.S. Public Health Service (PHS).Donald L. Weaver

NHSC established its loan repayment program in 1987, but pharmacists have not been considered in the permanent group of eligible clinicians, which includes physicians, nurse practitioners, physician assistants, certified nurse-midwives, dentists, dental hygienists, and mental and behavioral health professionals.

The Senate introduced legislation in March that would make loan repayments of up to $35,000 for each year served available for pharmacists who agree to serve in a health care facility with a critical shortage of pharmacists.

The Pharmacy Education Aid Act of 2003, S. 648, was passed by the Senate Health, Education, Labor, and Pensions Committee in June. The bill is pending.

Meeting critical shortages. Congress created NHSC in 1970 under the Emergency Health Personnel Act to meet staffing needs in primary and ambulatory care settings in medically underserved areas.

More than 23,000 clinicians have served in the program since 1972, said Weaver, a 28-year PHS veteran.

Weaver started his PHS career in 1975 as a NHSC volunteer in Tuella, Utah, where he served for three years as a family physician.

NHSC was originally established as part of PHS and all clinicians serving in the program were federal employees, he said. But the program has evolved to serve as a recruitment and retention agency that places mostly civilian clinicians at HPSA sites.

Most NHSC volunteers are employed by the communities or health centers in which they serve, Weaver said. About half of NHSC’s field strength practice in community health centers.

“Our two customers are underserved communities and clinicians, and our job is to match the two of them together as best we can and help facilitate that match,” he said. “We try to target the communities with the greatest need.”

About 45 of NHSC’s 2765 volunteers, he said, are PHS employees serving as ready responders—members of a mobile team of health professionals who are trained to respond quickly in the event of a large-scale regional or national medical emergency.

Weaver hopes to increase the ready responder cadre to at least 80 PHS employees.

About 60% of NHSC volunteers serve in “rural and frontier America,” Weaver said, with the remaining 40% employed in inner cities.

“We have clinicians in every state in the United States, the District of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, and the Pacific Basin,” he said.

Easing a burden. The loan repayment program gives clinicians who want to work in medically underserved areas the opportunity to do so, Weaver said.

Without the loan repayment opportunity, he added, clinicians might choose a job based on salary alone to meet financial obligations of a large educational debt and not seek opportunities where they have a great desire to work.

“We can help alleviate that [debt], and [clinicians] can get to a place where they are making a difference,” Weaver said. “We want to give them the opportunity to go where the needs are the greatest . . . to go where others choose not to go. We do whatever we can to work with the communities and the individual to create an environment where they want to stay for a long time.”

NHSC’s loan repayment program aids HPSA communities by “getting fully trained people out there right away,” Weaver said, “because communities needed clinicians yesterday, and they’ve got to have them today, and they for sure want to have them tomorrow, and they don’t want to have to wait.”

The number of loan repayments awarded each year is based on the amount of funding appropriated by Congress to NHSC, Weaver said.

“And this year we got an increase in appropriation, and we are going to do a significant number more than we have done in the past in loan repayments,” he said.

Congress appropriated $125 million—an increase of $26 million from last year—to NHSC for recruitment programs, such as loan repayments and scholarships, and about $46 million—about $200,000 less than last year—to support the division’s administrative needs.

Pharmacists awarded loan repayments. Even though pharmacists are not included as eligible clinicians for NHSC’s loan repayment program—other than the demonstration project underway—at least three pharmacists have received loan repayments from the program, Weaver said.

El Rio Santa Cruz Neighborhood Health Center in Tucson, Arizona, used a $249,886 HRSA grant to hire Clinical Pharmacist Sandra Leal in January 2001 to start a drug therapy management clinic for patients with diabetes mellitus.Sandra Leal

Leal’s pharmacy director encouraged her to apply for the NHSC loan repayment program, even though there was no place on the 30-page application for pharmacists to list details specific to pharmacy practitioners.

“So a lot of my application process was [writing] a cover letter just to explain what I did, what my position was, and how that related to other professions.”

Leal said she knew her application, which she submitted in 2001, was a “long shot.”

“But sure enough, I sent it in, and they paid my loans off, which is pretty amazing,” she said. Although Leal was eligible to receive up to $50,000 for her two-year commitment to NHSC, she only had $20,000 in educational debt.

Weaver said that, if $20,000 is the total amount owed for a student loan, that is the total NHSC will pay, even though a clinician must commit to serving the full two years.

More than debt relief. Leal said she considers the loan repayment a “bonus” for working in a medically underserved area.

“I didn’t know about the loan repayment program, and it wasn’t the reason I selected the job in the first place,” she said. “I really wanted to start the clinic just because there was a really important need with our patient population.”

El Rio Santa Cruz treats about 4000 patients with diabetes mellitus on a regular basis, Leal said, adding that she provides drug therapy management to patients under a collaborative practice agreement.

Leal, who speaks fluent Spanish, said she also chose to work at an HPSA site in Tucson because of a lack of bilingual health care providers in the area.

“I’m originally from Nogales, Arizona, a border town. I saw a lot of family and friends who didn’t speak English,” she said. “They didn’t have a [provider] that they could go to and speak to or have access to. That is one of the reasons I went into the profession, to try to be a more accessible provider and someone who could communicate in both English and Spanish to patients.”

Many of Leal’s patients speak only Spanish, she said.

“When a patient comes in and we see them, sometimes it’s the first time they are really able to understand what’s going on with their disease, how to get control, and I think a lot of it is the language issue and cultural issues. This is a perfect place. I feel like I really fit in here.”

Telepharmacy project. When HRSA awarded Community Health Association of Spokane (CHAS) a $250,000 demonstration project grant to implement a telepharmacy program, Chief Executive Officer Peg Hopkins pursued getting an NHSC loan repayment as an additional incentive to hire a pharmacist.

“The main reason we needed to get the loan repayment was that we were going through a huge pharmacist shortage, and we knew that we would never get anybody in there if we didn’t have this as an incentive,” Hopkins said.

CHAS, a four-facility health center organization in Spokane, Washington, hired Pharmacy Director Heather Byer in September 2000 to oversee the project.Heather Byer

Hopkins said she worked closely with Washington State University College of Pharmacy in Pullman to recruit Byer, who completed her doctor of pharmacy degree at the school.

HRSA required demonstration project grant applicants, such as CHAS, to partner with a school of pharmacy and at least one other community health organization.

CHAS opened its pharmacy at its Valley Medical Clinic in Spokane, Washington, in January 2001 and hired a second pharmacist, Kristi Heaton, a month later, Hopkins said.

Byer was awarded a $50,000 loan repayment for a two-year commitment to serve as an NHSC volunteer.

While the loan repayment was an incentive to take the job at CHAS, Byer said, she was already hooked on pursuing the job because of her interest in opening a pharmacy and establishing the telepharmacy program.

CHAS pharmacists use videoconferencing equipment to communicate with technicians and patients at CHAS sites, Byer said.

Byer or Heaton travels to each CHAS location once a week to stock automated dispensing machines with packaged unit-of-use medication containers, Heaton said.

The pharmacy also provides dispensing services to Native Health of Spokane and Northern Eastern Washington Selkirk Community Clinic, a health center located about 100 miles outside Spokane in a remote area of the state.

Prescribers fax orders to the Valley Medical Clinic pharmacy where a pharmacist prepares an electronic label, which pharmacy technicians at off-site locations access using CHAS’s computer system. When technicians at CHAS sites print the label, the automated dispensing machine dispenses the medication container.

Technicians scan the container and label using bar-code-scanning equipment before applying the label to the dispensed container.

The technician holds the labeled medication in front of the video camera where a pharmacist at the Valley Medical Clinic views it on the screen and confirms that it is the correct drug for the patient and that the order has been dispensed appropriately.

Hopkins said that Washington’s board of pharmacy gave her organization special approval so that technicians located at CHAS facilities could dispense medications with pharmacists overseeing the process using videoconferencing.

CHAS pharmacists also counsel patients at off-site locations using the videoconferencing system. All patients, Heaton said, must be counseled by a pharmacist before receiving a medication from the off-site pharmacy—a requirement mandated under the demonstration project and the state’s board of pharmacy.

CHAS’s telepharmacy, Byer said, has given patients who do not live near a health center with a pharmacy access to the critical prescription drugs they need and the opportunity, via videoconferencing, to receive medication counseling from a pharmacist.