Limited supply of primary-care docs sparks competition among healthcare providers

Federally qualified health centers that serve mostly poor and low-income families in distressed or rural communities have always had a tough time recruiting physicians. And now, it's getting even harder.

Health Center Partners of Southern California, a consortium of 17 community healthcare organizations with 126 sites, is in desperate need of 50 primary-care physicians. The patient population at the federally qualified health center network has grown significantly over the past few years.

“It's a problem that's always been there and it's getting worse,” said Henry Tuttle, CEO for Health Center Partners. “When care reimbursement equations call for higher rates for specialty services, it also tends to drain what was originally available in the primary-care pool. Physicians who come through training … select a specialty rather than to stay in primary care.”

To address the need, Health Center Partners has contracted with national search firms to identify more potential workers, increased the starting salary for would-be physicians, and is developing a loan forgiveness program as an added financial incentive. Tuttle sees such strategies as vital for attracting qualified candidates.

The limited supply of primary-care doctors and other clinical staff dedicated to the field has increased competition among healthcare providers to attract these key personnel. Federally qualified health centers often lose out in the scramble.

The larger health systems and hospitals have the wherewithal to offer lucrative signing bonuses and financial incentives to prospective employees. Community health centers do not.

“In any given market, whether it be small or large, there are at least 10 different delivery systems a family practitioner can practice in,” said Travis Singleton, senior vice president at physician search firm Merritt Hawkins. “That wasn't the world that we had 10 years ago.”

Many factors fuel the trend. One of the largest came with the implementation of the Affordable Care Act, as millions of newly insured Americans gained access to routine healthcare. Other causes include population growth, an increased elderly population and the likelihood that as many as one-third of the current physician workforce will retire over the next decade.

The confluence of factors has raised the possibility of a shortage of primary-care providers over the next decade. The Association of American Medical Colleges estimates the shortfall will reach between 14,900 and 35,600 physicians by 2025, according to a recent report.

A recent survey on physician recruiting by Merritt Hawkins showed family physicians are the most sought-after specialty for the 10th straight year. Urgent-care physicians, a growing alternative, have moved from 20th most requested in 2015 to ninth in 2016. Average starting salaries rose 13% to $225,000 in 2016 from a year earlier.

The nation's 1,200 community health centers are expected to be hit hardest by the shortage, experts say. The 10,000 primary-care physicians now at community health centers will need to be supplemented by an additional 15,000 providers over the next 10 years. The Obama administration, in its efforts to expand access in low-income communities, used $13 billion in ACA and Recovery Act funding to add 900 health centers over the past five years.

It's been a steady growth over the past decade—even before the ACA. Community health centers have doubled their clinical staff since 2005—to a workforce of more than 170,000 serving 24 million patients. Overall vacancy rates stand at 13% among the clinical workforce and 25% for family physicians, according to the National Association of Community Health Centers.

Community health centers traditionally relied on several federal programs to recruit clinical staff. The National Health Services Corps, launched in 1972, provides scholarships and loan repayment to lure primary-care providers. They get the aid in exchange for several years of service in underserved communities.

Many health centers also use the Teaching Health Center Graduate for Medical Education program, created by the ACA. It provides funding to federally qualified health centers to establish or expand medical education in primary care. A person who learns in a community is more likely to stay in that community.

Health centers are also using the U.S. State Department's J-1 Exchange Visitor and the H-1B Temporary Visitor visa programs to staff vacancies. The visas allow foreign physicians to work in federally designated shortage areas. Some states have set up loan repayment programs to attract more primary-care physicians and nurses to work in underserved areas.

But such sources are insufficient to meet the growing demand.

“I haven't even gotten a resume from an individual that's an H-1B or J-1 visa in I don't know how many years,” said John Mengenhausen, CEO for Horizon Health Care, a federally qualified health center with 24 sites across rural South Dakota. Horizon services an area spanning 26,000 square miles where the average town ranges between 1,000 and 15,000 residents. “That opportunity has dried up,” he said.

Mengenhausen said funding cuts to NHSC and Teaching Health as well as changes to the law that allowed participants in J-1 and H-1B to work at larger health systems in the state have contributed to a sharp decline in the number of individuals willing to serve in rural areas.

Another part of the problem in recruiting staff was the historic reliance by community health centers on attracting mission-driven physicians motivated to serve the poor. More than three-quarters of the patients who visit such facilities are either uninsured or covered by Medicaid. Fully 72% earn below 100% of the federal poverty level.

But today's physicians come out of medical school with huge financial debts, and the need to begin repaying their loans trumps their idealism. According to the AAMC, the median medical education debt for 78% of graduates in 2015 was $180,000. That leads them to seek out more lucrative opportunities, even if they're willing to go into primary care.

“The influence of the debt burden and the relative lack of reimbursement for primary care in general is of course leading more and more of the medical school graduates away from primary care,” said Cindy Ehnes, executive vice president of Health Care Talent Innovations at COPE Health Solutions.

Singleton said health centers will need to look at new approaches if they hope to maintain adequate staffing levels. “You're going to have to elevate your brand past those avenues,” he said. “You're going to have to reach a new generation of providers that have no idea who you are.”

Using a home-grown approach has been effective for some community health centers. They either partner with an academic medical organization to develop or expand residency or student training, or establish their own programs with hopes that trainees will pursue careers in community healthcare settings.

“Because we are a teaching institution, we are better off than some,” said Sherri Peavy, chief operations officer for Miles Square Health Center, a Chicago-based federally qualified health center serving 18,000 patients a year in underprivileged parts of the city. “We get them early in their careers; they come over and get fired up about community health.”

In 1990, Miles Square became a part of the University of Illinois Hospital and Health Sciences System, a partnership that led to development of the health center's medical education programs that it now offers for physicians, nurses, midwives and pharmacy students.

For health centers in rural and semirural areas, collaborating with the nearest academic medical centers can be difficult, however. The remoteness of some locations can make it extremely difficult to attract qualified candidates.

“We struggle recruiting healthcare providers, and we do everything you can think of,” Mengenhausen said. “We've tried the recruitment firms ... but not (with) a great deal of success.”

Many health centers have had to market some of their more intangible benefits such facilities can offer over larger health systems. One selling point has been the flexibility in hours and schedules health centers can provide compared with large-scale health providers, allowing for a better work-life balance.

“We have seen over the past three or four years an increasing self-reported importance for normal work hours, work-life balance, and consistency in daily routines,” said Dorrie Guest, director of Physician Enterprise and Ambulatory Services practice at Deloitte Consulting. Another aspect of community health centers that Guest said attracts young physicians is the opportunity to practice medicine in a team-based medical home-style setting.

But that advantage may be on the wane as more providers adopt clinical-care models that resemble the ones used by health centers.

“We're truly moving the FQHC-mission model over to the hospital-based, independent practice type of organization,” said Pam Ballou-Nelson, a senior consultant with MGMA Health Care Consulting Group. “More physicians are coming out of school today realizing that model is what we really need to strive for. If the traditional health systems move toward that model, it might mean more competition for FQHCs.”