Physician Shortage Widespread at Community Health Centers

In a national survey, well over half of community health centers had at least one vacancy for a family physician, according to a report published in the August issue of American Family Physician.

Among the 1278 health centers that received the National Association of Community Health Centers (NACHC) survey in 2016, 499 (39%) responded. Of those, 69% reported at least one vacancy for a family physician, up from just 13.3% in 2006.

Moreover, recruitment for a family physician took, on average, 11.4 months; only positions for psychiatrists took longer to fill.

Slightly more than half of the respondents (51%) said that filling a family medicine position was their highest priority.

NACHC estimates that health centers currently serve more than 27 million patients in more than 10,000 communities compared with serving 10 million patients in 2000. If all positions were filled, NAHCH estimates, 2 million more patients could be treated.

Patients treated at community centers are predominantly low income, uninsured, or on Medicaid, and belong to racial or ethnic minorities. Many have complex and chronic conditions. NAHCH says the clinics save about $24 billion annually by reducing hospitalizations and emergency department visits.

Recruiting and Retaining Family Physicians

Community health centers are a "critical component of the primary care safety net," Caitlin Crowley, MPH, from the NACHC and colleagues write in the new report. Family physicians make up much of that safety net, comprising 46% of all health center physicians.

Although more family physicians are in training, it is not clear whether the growth will be adequate. According to the March 2018 National Residency Matching Program, the number of new physicians choosing family medicine increased for the ninth consecutive year, to 3535. But the growth may mirror an overall increase in the number of medical school graduates rather than a growth in family medicine, per se, said Andrew Bazemore, MD, MPH, director of the Robert Graham Center in Washington, DC, and senior author on the new survey report.

Several programs aim to increase physician employment at community health centers. For example, "mega teaching health centers" that link community clinics to academic medical centers or teaching hospitals aim to increase access for Medicaid beneficiaries, according to a recent article published in the New England Journal of Medicine.

"Evidence is limited on what really works, such as loan repayment programs at community health centers, but many efforts focus on improving partnerships between academic medical centers and community health centers," Efrain Talamantes, MD, MBA, associate director of the Center for Reducing Health Disparities at the University of California, Davis, School of Medicine, told Medscape Medical News.

Talamantes mentions the ACE-Primary Care program at the University of California, Davis, Medical School, which is run in partnership with Kaiser Permanente. This program "and others at universities throughout the country are attempting to create stronger linkages between medical student training and community health centers."

Encouraging more students to pursue primary care is another approach. For example, the first 30 medical students at the University of Houston's College of Medicine, set to open in fall 2020, will receive free tuition, thanks to a grant, with preference for admission given to students who plan to enter primary care.

The Funding Situation

Historically, salaries at community health centers have been a hindrance to attracting family physicians and other professionals. Funding is increasing, but not enough to keep pace with demand, given the vacancies. In the 2016 survey, 95% of centers reported at least one opening for a physician.

The centers began as a pilot project during President Johnson's War on Poverty to provide care for Medicare recipients. Then the Affordable Care Act established the Community Health Center Fund, which grew from $1 billion in 2011 to $3.6 billion in 2017, in annual appropriations and grants. The Health Resources and Services Administration oversees the program. But none of the funding sources are stable or provide long-term guarantees, which makes building a physician pipeline difficult.

For example, initial Community Health Center Fund authorization in 2010 covered 5 years. Two, 2-year extensions followed in 2015 and 2017. The fund received $1.6 billion from discretionary funds and $3.8 billion from the Community Health Center Fund in the Bipartisan Budget Act of 2018, which also earmarked $4.0 billion in mandatory funds for 2019.

The Affordable Care Act also established Teaching Health Centers Graduate Medical Education residency programs, which Talamantes called "an important paradigm shift that may allow more physicians to train in community health centers and therefore stay in those practices." The Teaching Health Centers Graduate Medical Education budget extended to 2019 is $1.26 billion, the same as for 2018 and approximately double that for 2016 and 2017.

But the Teaching Health Centers Graduate Medical Education funding pie has to be sliced well beyond family medicine to include dentistry, pediatrics, internal medicine, and other specialties. When the program began, primary care residents received $150,000 a year for 2 years. After a reevaluation, the 2015 congressional reauthorization slashed that amount, to $95,000 per resident per year, according to Health Resources and Services Administration.

Short-term funding cycles are particularly problematic for trainees. "Training in family medicine is 3 years, and with 2 years of promise with the funding extension, it's not easy to commit to a residency," Bazemore said. That "very short term funding stream" may explain some reticence among family medicine graduates in accepting residencies at health centers.

Training in Place

Medical students and residents who train primarily in academic teaching centers may have limited experience in community health centers and are more likely to eventually practice in the academic medical centers, Talamantes said. Similarly, trainees who spend time in community health centers are likely to stay there. In fact, studies show that 40% of teaching health center graduates go on to practice in the centers.

Similarly, the NACHC survey shows that from 2014 through 2016, 58% of community health centers hired a health professional who trained at their center and 30% hired a physician who trained at another health center.

"If we train in the places that are not just based on geography, but the settings where we want people to practice, we might get more of them," Bazemore said.

"Teaching health centers hold great promise, but we agree [with Crowley and colleagues] that these findings highlight the need for policymakers to support federal programs that create incentives and provide community-based primary care training," Talamantes said.

Concluded Bazemore, "When do you start recognizing the return on the investment, and look for ways to make these programs permanent? We need something to prop the system up."

The authors and commentator have disclosed no relevant financial relationships.

Am Fam Physician. 2018;98(3):146. Abstract

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