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Case Study

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

20 Minute Read

Overview

The challenge

In the United States, a growing shortage of primary care physicians is projected to impact millions of patients. Safety net health systems that provide care to low-income patients, including uninsured and Medicaid populations, struggle to offer competitive physician salaries. Primary care physicians facing financial pressure from educational debt may be influenced to seek higher paying positions, resulting in a severe impact to vulnerable patients as the physician shortage worsens. More than ever, candidates from underrepresented racial and ethnic backgrounds need support to enter health care professions and commit to serving vulnerable communities.

The organization

L.A. Care Health Plan is the nation’s largest publicly operated health plan serving more than 2.5 million members. Established in 1997, L.A. Care’s mission is to provide access to quality health care for Los Angeles County’s vulnerable and low-income populations and to support the safety net systems in place to serve them.

The approach

L.A. Care launched the Elevating the Safety Net (ESN) initiative in 2018, with a commitment of $155 million dollars over five years to support the recruitment and retention of physicians from underrepresented racial and ethnic groups into Los Angeles County's safety net. A core program of the ESN initiative is the Provider Loan Repayment Program (PLRP). This initiative awards primary care providers up to $180,000 in exchange for a three-year commitment to practicing in the safety net. L.A. Care approached the creation of the PLRP by assessing gaps in their workforce, creating clear application criteria, establishing strategic community partnerships, and integrating this program into their larger ESN initiative.

The result

Since program launch in 2018, L.A. Care has distributed over 100 PLRP awards to primary care physicians, with 64% of awardees identifying with an underrepresented racial/ethnic group in medicine. The PLRP cohort has an 89% retention rate, and L.A. Care plans to sustain multi-year grants in addition to the nearly $26 million already committed to the program. This initiative has successfully recruited providers and created a competitive advantage to attract primary care physicians into safety net settings.

 

Approach

L.A. Care is a publicly operated health plan seeking to improve the supply and diversity of physicians serving in safety net settings. Its investment into the Provider Loan Repayment Program (PLRP) is an example of meaningful commitment to diversity, equity, and inclusion (DEI). While L.A. Care does not directly recruit or pay physicians, it identified physician loan repayment as a way to address the primary care workforce shortage in their community, support safety net providers unable to pay higher salaries, and strengthen the care system for their underserved, low-income members. L.A. Care's PLRP, and the broader overall ESN initiative, is an excellent example of a health plan investing financial support and creating infrastructure to advance DEI in its community.

As of 2022, nearly $26 million of the ESN initiative funds have been dedicated to the Provider Loan Repayment Program.

The design of the PLRP was guided by a diverse set of stakeholder groups, including L.A. Care board members, who represent members, consumers, federally qualified health centers, hospital systems, the Los Angeles Department of Health and Social services, children's health care providers, private practices, and community clinics.

 

The four strategies

L.A. Care approached the creation and implementation of the PLRP with four key strategies:

  • Strategy

    Design program to account for local context

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  • Strategy

    Create clear application criteria

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  • Strategy

    Establish strategic partnerships to facilitate program administration

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  • Strategy

    Consider extending financial support to safety net employers and medical students

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Results

How we know it’s working

As of 2022, L.A. Care has distributed 108 PLRP awards to primary care physicians, with 96 current active awards. Of the providers receiving awards, 42% are licensed in family medicine, 32% in pediatric medicine, 18% in internal medicine, 6% in psychiatry, and 2% in obstetrics/gynecology.

The PLRP also supports improved care for Medi-Cal members, with 54% of awardees practicing in a Federally Qualified Health Center, 24% in a Los Angeles County Department of Health Services facility, 13% in a medical group, 2% in private practice, and 7% in a Los Angeles County Department of Mental Health facility (where psychiatrists can serve Medi-Cal members in a co-located primary care setting).

Underrepresented racial and ethnic groups are well represented among the PLRP awardees. L.A. Care reports that the awardees are 16% Asian, 9% Black or African American, 28% White or Caucasian, 21% Hispanic or Latinx, 12% Native Hawaiian or Pacific Islander, and 14% other. Gender representation is 65% female and 35% male. In addition, the languages spoken by PLRP providers (other than English) include: 43% Spanish, 5% Mandarin (Mandarin Chinese), 4% Armenian, 4% Cantonese (Yue Chinese), 4% Tagalog, 3% Farsi (Persian), 2% Korean, 1% Russian, 1% Arabic, and 19% other, including no response.

Of the 108 providers who have received PLRP awards, only 12 did not complete their three-year service commitment and 4 of them paid off their debt before the completing the commitment. Overall, L.A. Care has a nearly 89% retention rate for the PLRP cohorts.

This data demonstrates that the PLRP successfully recruits diverse providers and creates a competitive advantage to attract primary care physicians into safety net settings. L.A. Care’s approach serves as a model for intentional design and thorough implementation in efforts to advance workforce diversity and equity while also addressing clinician shortages.

What’s next

As L.A. Care completes the last year of its five-year funding commitment, the organization has a clear plan in place for ensuring that the Provider Loan Repayment Program can continue supporting physicians who commit to practicing in safety net settings. In 2021, L.A. Care’s board of governors approved a new grant of $7.96 million to provide loan repayment awards to 30 to 60 new providers. The organization also plans to extend existing awards by an additional two years for up to 22 providers who completed their three-year service commitment yet have remaining educational debt. Moving forward, L.A. Care plans to sustain multi-year grants and contracts, identify alternative and matching funds that can strengthen the PLRP, and establish partnerships to expand support for their local safety net workforce for an additional five years, through 2027. To ensure the longevity of the program, L.A. Care is conducting an evaluation to assess the investments made to date, identify priority areas for funding to support DEI among the local physician workforce, and explore new opportunities to secure funding.

This strategic vision for financial sustainability is a critical component that maximizes the impact of the PLRP. With secured funding for loan repayment awards, L.A. Care can continue advancing workforce equity by building its network of diverse providers committed to practicing in safety net settings.

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