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Are IBR and PSLF an answer to increasing the PC Physician workforce?

GREAT NEWS!!! for students interested in Primary Care (PC).  The government has two programs that could make the career choice in PC much more feasible: Income Based Repayment (IBR) and the Public Service Loan Forgiveness (PSLF).

In a recent article titled, “Economic Impact of a Primary Care Career: A Harsh Reality for Medical Students and the Nation”, Academic Medicine, Vol. 85, No.11/November 2010, it gave some good insights on the potential for medical students to stay away from PC.  The purpose of the article was to give the reader an idea of factors that contribute to the decrease in medical students choosing PC careers.  Financial security in the setting of rising medical student debt is often cited as a reason to pursue other more lucrative medical specialties.  The authors sought to quantify the financial factors associated with a career in PC.   Becoming a physician involves many expenses, which include predominantly educational loan costs, lost opportunity costs, and delayed savings and investment penalties.

The methods used included a variety of factors, to develop a net income and expense model.  They attempted to account for the variability of factors by looking at best, worst and average expense scenarios.   As a result, PC salaries, in contrast to other subspecialties, result in an initial budgetary deficit and decreased discretionary spending.  The gap decreases as  PC physician income rises in the first few years of practice.  Only under scenarios of optimal low cost assumptions or no debt do a PC physician’s initial earnings exceed predicted expenses.

So, the conclusion was that PC physicians, in the first three to five years following residency, will have expenses that exceed earnings.  This reality greatly increases the financial disincentive for pursuing a career in PC compared with other fields of medicine.

Given these observations, perhaps with the IBR Plan and the possibility of utilizing the PSLF Program, it will an impetus for change and make the PC choice more palatable.  The fact that the IBR can now make Federal loan payments more manageable, it may contibute to decreasing or potentially eliminating the income/expense issue.  With the added incentive of loan forgiveness with the PSLF as long as the PC physician works in a not-for-profit capacity (at least 30 hours per week) for 10 years from the beginning of IBR.

With the passage of the Patient Protection and Affortable Care Act (PPACA) in March 2010, it relies heavily on a strong PC Physician workforce.  There is a growing amount of evidence that increased reliance on subspecialty care leads to higher health care costs, increased mortality and lower health care quality.  Also, guranteeing health care coverage does not guarantee health care access, as discovered by Massachusetts.  Finally, improved preventive care services and decreased emergency room care does not give you financial and health advantages.  There is evidence that access to PC physicians does increase high-quality health care.

Perhaps there needs to be a serious conversation to close the salary gap between PC Physicians and Subspecialists to ensure that quality care models and reimbursements align as well as provide loan repayment incentives directed to PC Physician debts.  If England can do it, why can’t we?

The views expressed in this content represent the perspective and opinions of the author and may or may not represent the position of Indiana University School of Medicine.

Jose Espada

Jose Rivera Espada is the director of financial aid at IU School of Medicine, a nine-campus allopathic medical school in Indiana. Jose’s experience includes working as an assistant director of financial aid at Butler University and a financial aid coun...