How L.A. Care designed a provider loan repayment program

L.A. Care grounded the design of the Provider Loan Repayment Program in evidence they obtained from analyzing the specific characteristics and needs of their service region.

Prior to launching the PLRP, L.A. Care conducted research to identify the impact of the primary care physician shortage on their members. As of 2017, Los Angeles County had 48 primary care providers per 100,000 people in comparison to the recommended 60 to 80. Moreover, according to a July 2020 report from the California Health Care Foundation, among the over 10 million people living in Los Angeles County, over 3.7 million live in an area with a shortage of primary care health professionals, including nearly 59,000 people who are experiencing homelessness—many of whom have extensive health needs.

L.A. Care recognized that Medi-Cal (California's Medicaid Program) populations are among the most severely impacted by the primary care shortage. Safety net employers struggled to offer competitive salaries and loan repayment programs compared to larger and for-profit health care employers. Primary care physicians, while often expressing a desire to serve in safety net settings, also face financial pressures from educational debt that may influence their decisions to take higher paying jobs.

L.A. Care also conducted a demographic analysis of their Medi-Cal membership, finding that nearly 40% identified as Hispanic or Latino and that 37% listed a preferred language other than English, including 27% who listed Spanish as their preferred language. L.A. Care wanted to build a workforce to better reflect their members.

L.A. Care saw an opportunity as a publicly operated health plan to support the safety net systems that provide health care to most of their members and improve representation in the local workforce. In July 2018, L.A. Care established the Provider Loan Repayment Program to increase the supply, distribution, and diversity of physicians who commit to serving in safety net settings.

The design of the PLRP was further guided by consultations with similar programs focused on mitigating workforce shortages. L.A. Care modeled their program after the Office of Statewide Health Planning and Development's (OSHPD's) Steven M. Thompson Physician Corps Loan Repayment Program, which focuses on increasing physician retention for medically underserved areas of California. However, while OSHPD’s program awards physicians $105K for a three-year commitment, L.A. Care instituted a $180K maximum reward based on the high cost of living in Los Angeles County to offer a competitive alternative. Tailoring the loan repayment award to account for local context was critical to ensure successful recruitment of providers.

Early in the program, L.A. Care also decided to track four main data domains to measure the impact of the program:

Primary care physicians are eligible to apply for the Provider Loan Repayment Program if they meet a rigorous set of requirements. The criteria below allow L.A. Care to capture the right applicants and make progress toward the goals of attracting, retaining, and growing the network of physicians who commit to practicing in a safety net setting.

To be eligible for a Provider Loan Repayment Program award, a primary care physician must:

• Practice in an eligible specialty, including family medicine, internal medicine, obstetrics/gynecology, pediatrics, or psychiatry
• Be new to L.A. Care’s Medi-Cal network
• Apply within six months of being hired by a qualified safety net practice site
• Provide board eligibility or certification in one of the approved specialties
• Clear L.A. Care’s credentialing process
• Commit to practicing in the safety net for at least 36 months
• Provide at least 16 hours of direct patient care per week
• Demonstrate financial need based on outstanding educational debt
• Demonstrate cultural and linguistic competency, although not required to speak a Medi-Cal threshold language
• Complete all application materials
• Submit annual reports summarizing outstanding educational debt and payments in the last year
• Participate in post-program survey activities to evaluate program effectiveness

Prior to establishing the Provider Loan Repayment Program, L.A. Care evaluated its organizational capabilities and sought support for facilitating logistics. L.A. Care partners with an external organization, Uncommon Good, to manage the administration of the loan repayment awards. Uncommon Good is a nonprofit organization based in Claremont, California. Uncommon Good’s mission is to break the intergenerational cycle of poverty through programs in education, health, and environmental health, and this organization has administered programs similar to the PLRP for over 20 years. Specifically, Uncommon Good had experience facilitating a program called Medicine for Economically Disadvantaged (MED), which provides educational loan repayment assistance to health practitioners in return for serving low-income populations.

Each year, L.A. Care allocates a lump-sum grant to Uncommon Good—this started at $3 million in 2018 and has risen to $7.96 million in 2022. Uncommon Good then reviews PLRP award applications, makes recommendations to L.A. Care for funding considerations, and disburses the monthly awards to the individual physicians. Uncommon Good also administers a post-program survey to collect qualitative data from physicians who exit the program (either upon contract completion or early departure), which enables assessment of provider satisfaction and areas for future improvement. While L.A. Care provides the data infrastructure and financial support necessary to run the program, Uncommon Good’s community knowledge and program management experience enables smooth facilitation of the Provider Loan Repayment Program.

L.A. Care recognized that addressing the workforce shortage and improving the racial/ethnic diversity of the health care workforce requires a multipronged approach. The Provider Loan Repayment Program is one of three core components within Elevating the Safety Net (ESN), L.A. Care’s umbrella initiative focused on recruiting physicians to L.A. County’s safety net.

L.A. Care launched the ESN initiative in 2018 with three core programs: the Provider Loan Repayment Program, a Provider Recruitment Program, and a Medical School Scholarship Program. The Provider Recruitment Program awards safety net employers up to $125,000 per primary care provider hired and committed to at least three years of practice in the safety net. The Medical School Scholarship Program awards full-tuition scholarships to students who demonstrate financial need, come from disadvantaged backgrounds, and express a sincere commitment to practicing in the safety net upon completion of their medical training.

Since 2018, L.A. Care has added seven programs to the ESN initiative focused on mobilizing community partners to support the health care workforce:

• Residency Support Program: Dedicated funding for new residency positions to expand local medical training in underserved community settings
• IHSS+ Home Care Training Program: Offers a 10-week curriculum that educates and empowers caregivers who provide services for home-bound seniors and persons with disabilities
• Community Health Worker (CHW) Training Program: 9-week course in collaboration with Loma Linda University to integrate CHWs in the primary care workforce serving vulnerable populations
• National Medical Fellowships: 6-week service-learning experience that matches medical school students to community health centers in Los Angeles and provides them with a $5,000 stipend
• Health Career Connection Internship Program: 8-week summer internships for undergraduate students designed to encourage future pursuit of health care careers and offers a $4,200 stipend
• Keck Graduate Institute (KGI) School of Medicine Support Program: $5 million grant covering full tuition for 45 students from underserved communities to pursue a master’s degree in community medicine in conjunction with the MD degree
• Charles R. Drew University of Medicine and Science – New Medical Education Program: $5 million grant to expand the availability of medical training in underserved communities by supporting key components of the program, which is set to welcome the first class of 60 new medical students starting in 2023

L.A. Care launched the Elevating the Safety Net initiative with a commitment of $155 million over five years and has invested nearly $93.6 million across 10 programs. (As of December 2021, nearly $26 million went specifically to PLRP awards.) Beyond providing an incentive to individual providers to enter the safety net practice setting, L.A. Care’s approach enables multiple stakeholders to benefit—employers are incentivized to hire primary care providers, and students still in medical school can begin exploring options for their future careers. The presence of these programs within the larger structure of the ESN initiative contributes to the success of the PLRP by enabling a holistic approach to physician recruitment and retention. L.A. Care looks for synergies across the individual ESN programs. For example, the health plan encourages qualified practice sites to apply to the Provider Recruitment Program and tell prospective employees about the PLRP.