UMass Medical School survey finds community health centers facing declining numbers of primary care physicians

March 18, 2015

A UMass Medical School survey of primary care physicians at Massachusetts community health centers finds an aging workforce with fewer doctors planning to continue working in the centers in the next five years.

“If we want health care reform to succeed, community health centers must have the workforce to deliver care,” said Linda J. Cragin, director of the Massachusetts Area Health Education Center (MassAHEC) Network, a unit within UMass Medical School’s Commonwealth Medicine, and a member of the team that conducted the survey on recruitment and retention of primary care physicians at community health centers.

An initial survey was done in 2008, shortly after Massachusetts implemented health care reform, and the follow-up survey in 2013 gauged its effect on community health centers. The surveys were done by the MassAHEC Network and the Massachusetts League of Community Health Centers, with expertise from Commonwealth Medicine’s Center for Health Policy and Research and the Department of Family Medicine & Community Health.

The 2013 survey found that only 63 percent of the primary care physicians plan to continue working in community health centers over the next five years, with an additional 17 percent uncertain about whether they will continue practicing in a community health center, and the remaining 20 percent stating that they would likely not be employed in a community health center.

“That’s a very large proportion of the physician workforce leaving community health centers, especially at a time when fewer physicians are going into family medicine,” said Warren Ferguson, MD, who works part time at a community health center. The reduced number of physicians choosing primary care as a discipline compounds the problem, said Dr. Ferguson, a professor in Family Medicine & Community Health at UMass Medical School and medical director of MassAHEC Network. He said there will be a smaller family medicine workforce in 10 years; 41 percent of the survey respondents are family medicine physicians.

In addition, the number of doctors planning to retire in the next five years has nearly doubled since 2008. In 2013, 9 percent reported plans to retire in the next five years, while 5 percent said in 2008 they planned to retire in the next five years.

“I think it’s the tip of the iceberg,” Ferguson said. “If we redo the report in five years, my guess is we’ll see another doubling.”

The potential loss of federal funding in 2015 could force additional staff reductions. The National Association of Community Health Centers warned March 17 that a major source of federal funding for community health centers will expire Oct. 1. If Congress doesn’t restore the funding, which supports health centers by up to 70 percent, about 57,000 clinicians and staff could be laid off and 7.4 million patients could lose access to care nationwide, according to the NACHC.

Community health centers serve the most vulnerable populations in medically underserved areas, including those who have substance abuse and mental health issues and have suffered trauma, as well as those who speak languages other than English. Community health centers are an important component of health care reform and provide high-quality, cost-effective care. They are working on transformation to patient-centered medical homes, but recruiting and keeping primary care physicians is a challenge.

“There are a number of challenges with community health centers in their efforts to both recruit and retain their workforce – among them the issue of physicians aging out of the workforce, especially those who have been in a health center environment for 20 to 30 years,” said Judith Savageau, MPH, project lead and an evaluator with the Research and Evaluation Unit at the Center for Health Policy and Research.

The 2013 survey was sent to about 600 primary care physicians in 46 community health centers. Of those, 301 physicians in 44 community health centers responded.

In 2013, 21.7 million people were treated at community health centers throughout the U.S., according to the Health Resources and Services Administration. Ninety-three percent of those were below 200 percent of the poverty level, 73 percent were below 100 percent of the poverty level, and 35 percent were uninsured. In Massachusetts, community health centers serve one out of every eight residents.

One of the most important factors in physicians’ decision to work in community health centers is the belief in their mission and the diversity of the patients served, and that commitment has remained strong since the 2008 survey, Savageau said.

“The mission hasn’t dwindled over time,” she said.

Doctors responding to the survey also cited professional development, work-life balance, support from the community health center leadership for their practice goals, compensation and loan repayment as key considerations when choosing to practice or remain in a community health center.

“While these administrative supports are on target, I also believe physicians don’t talk enough about how hard it is to take care of the population we take care of,” Ferguson said.

Because patients at community health centers can be complex and while we can be committed to the mission, he said, “It does take a toll.” Ferguson said the results of the survey don’t address that aspect of work in community health centers because the survey didn’t include questions about the difficulty of caring for patients from vulnerable populations.

Among the differences between 2008 and 2013 are that more physicians are being trained to work with patients who are treated at community health centers, and the implementation of electronic health records, which has made life harder for them because they spend more hours a week documenting health information, Ferguson said. Sixty percent of family medicine resident physicians in Massachusetts are now training in community health centers, he said.

A report on the 2013 survey advises community health center executives and community boards that compensation, productivity incentives, the quality of care and benefits must be periodically reviewed and adjusted to retain the third of the workforce who have been at the centers less than five years.

“Physicians who work in community health centers come with a strong desire to do that, but without payment reform and primary care transformation, there will continue to be workforce problems that will only get worse because of an aging population,” Ferguson said.