ORIGINAL CONTRIBUTION
Shortages of Medical Personnel
at Community Health Centers
Implications for Planned Expansion
Roger A. Rosenblatt, MD, MPH
C. Holly A. Andrilla, MS
Thomas Curtin, MD
L. Gary Hart, PhD
RESIDENTS OF THE UNITEDStates lack universal access tohealth care, and millions ofpeople have difficulty obtain-
ing medical care.1,2 The year 2005
marked the 40th anniversary of one of
the nation’s most enduring attempts to
emedy this problem: the creation of
community health centers (CHCs) as
part of the “war on poverty.”3-8 The na-
tional importance of these centers has
grown during the ensuing 4 decades,
and the federal government provides
funding through a variety of categori-
cal mechanisms under the collective
term federally qualified health centers.
CHCs provide medical, dental, and
mental health care for migrant work-
ers, the uninsured, the homeless, and
others in need, and the number of
people they have served has expanded
apidly in the 21st century.9
The role and responsibility of CHCs
have increased as more people in the
United States have difficulty gaining ac-
cess to medical care.10 CHCs now pro-
vide care to more than 14 million US
esidents in more than 3500 commu-
nities.9 Governed by nonprofit boards
with majority representation from the
patient population served, CHCs are
different from the private practices and
for-profit entities that deliver most am-
ulatory care in the United States.11
A national decision to invest fur-
ther in CHCs has occu
ed during a pe-
iod when access to health care in the
United States is limited for more peopleFor editorial comment see p 1062.
Author Affiliations: WWAMI (Washington, Wyo-
ming, Alaska, Montana, Idaho) Rural Health Re-
search Center, Department of Family Medicine, Uni-
versity of Washington, Seattle (Drs Rosenblatt and Hart
and Ms Andrilla); and National Association of Com-
munity Health Centers, Bethesda, Md (Dr Curtin).
Co
esponding Author: Roger A. Rosenblatt, MD,
MPH, University of Washington, Department of Fam-
ily Medicine, Box 354696, Seattle, WA XXXXXXXXXX
( XXXXXXXXXX).
Context The US government is expanding the capacity of community health cen-
ters (CHCs) to provide care to underserved populations.
Objective To examine the status of workforce shortages that may limit CHC ex-
pansion.
Design and Setting Survey questionnaire of all 846 federally funded US CHCs that
directly provide clinical services and are within the 50 states and the District of Co-
lumbia, conducted between May and September 2004. Questionnaires were com-
pleted by the chief executive officer of each grantee. Information was supplemented
y data from the 2003 Bureau of Primary Health Care Uniform Data System and weighted
to be nationally representative.
Main Outcome Measures Staffing patterns and vacancies for major clinical dis-
ciplines by rural and u
an location, use of federal and state recruitment programs,
and perceived ba
iers to recruitment.
Results Overall response rate was 79.3%. Primary care physicians made up 89.4%
of physicians working in the CHCs, the majority of whom are family physicians. In
ural CHCs, 46% of the direct clinical providers of care were nonphysician clinicians
compared with 38.9% in u
an CHCs. There were 428 vacant funded full-time equiva-
lents (FTEs) for family physicians and 376 vacant FTEs for registered nurses. There were
vacancies for 13.3% of family physician positions, 20.8% of obstetrician
gynecologist positions, and 22.6% of psychiatrist positions. Rural CHCs had a highe
proportion of vacancies and longer-term vacancies and reported greater difficulty fill-
ing positions compared with u
an CHCs. Physician recruitment in CHCs was heavily
dependent on National Health Service Corps scholarships, loan repayment programs,
and international medical graduates with J-1 visa waivers. Major perceived ba
iers to
ecruitment included low salaries and, in rural CHCs, cultural isolation, poor-quality
schools and housing, and lack of spousal job opportunities.
Conclusions CHCs face substantial challenges in recruitment of clinical staff, par-
ticularly in rural areas. The largest numbers of unfilled positions were for family phy-
sicians at a time of declining interest in family medicine among graduating US medical
students. The success of the cu
ent US national policy to expand CHCs may be chal-
lenged by these workforce issues.
JAMA. 2006;295: XXXXXXXXXXwwww.jama.com
1042 JAMA, March 1, 2006—Vol 295, No. 9 (Reprinted) ©2006 American Medical Association. All rights reserved.
Downloaded From: http:
jama.jamanetwork.com/ by a Oklahoma State University User on 07/16/2014
than ever before in the country’s his-
tory.10,12,13 Ongoing plans include a
5-year initiative that will increase fed-
eral spending on CHCs by at least $2.2
illion through fiscal year 2006 and
substantially increase the number of
treated patients.14-17
We examined the status of the health
care workforce in CHCs in the United
States, with particular attention to the
types of personnel who are most diffi-
cult to recruit and retain. Rural health
care delivery systems are smaller and
less well staffed than their u
an coun-
terparts; 20% of the US population lives
in rural areas but only 9% of physi-
cians practice there.18,19 We therefore
also examined whether workforce
shortages are more acute in rural CHCs
and whether rural and u
an CHCs dif-
fer in their staffing patterns, the source
of their clinicians, and their ability to
etain clinicians.
METHODS
The study was undertaken by the Ru-
al Health Research Centers of the Uni-
versity of Washington and the Univer-
sity of South Carolina and the National
Association of Community Health Cen-
ters (NACHC). A questionnaire was
created and pretested with the assis-
tance of an advisory committee com-
posed of representatives from the Of-
fice of Rural Health Policy, Bureau of
Primary Health Care (BPHC), and Bu-
eau of Health Professions, all compo-
nents of the Health Resources and Ser-
vices Administration of the US Public
Health Service. For questions about per-
ceived ba
iers to recruitment, respon-
dents answered on a 4-point scale
(1=not important, 4=important), and
the answers were dichotomized into im-
portant or not important. The survey
instrument and research methods were
eviewed and approved by the Office of
Management and Budget and by the in-
stitutional review boards of the partici-
pating universities.
The study population included the
890 nonprofit organizations that re-
ceived funding from the federal govern-
ment’s Section 330 Consolidated Health
Center Program15 and reported data to
BPHC’s Uniform Data System (UDS) as
of 2004. We excluded grantees that did
not directly provide general clinical ser-
vices or were outside of the 50 states and
the District of Columbia, leaving a sam-
pling frame of 846 grantees.
The survey instrument was mailed
to the chief executive officer of each
grantee, with a cover letter from
NACHC, on May 7, 2004. A reminde
postcard was sent on May 21, and a sec-
ond mailing and questionnaire with a
new cover letter was sent to nonrespon-
dents on June 11. After 2 mailings, all
nonrespondents from rural CHCs were
surveyed by telephone between Sep-
tember 2 and 17 and asked a subset of
the original questions restricted to cli-
nician supply issues. The final re-
sponse rate was 79.3%, ranging from
85.3% for the largest grantee category
(CHCs without other federal funding
sources) to 50.9% for the CHCs that re-
ceived funding solely as homeless cen-
ters. Rural grantees’ response rate (in-
cluding the minimal data set obtained
y telephone) was 97.5%; u
an cen-
ters’ response rate was 68.5%. Exclud-
ing the 2 categories of centers with re-
sponse rates below 60% did not change
the results.
U
an and rural designations are
ased on the ZIP code version of the Ru-
al-U
an Commuting Area (RUCA)
classification system.20,21 Because of dif-
ferential response rates between orga-
nizations in u
an and rural locations,
as well as regional differences, survey re-
sults were weighted to make them na-
tionally representative. Weights were
tested by being applied to survey re-
sponses and comparing the results with
UDS variables, including CHC type, size,
and patient population. Many CHCs
have multiple clinical sites, but each re-
ports data to the federal government only
in aggregate. Therefore, the results re-
ported apply to the grantee as a total en-
tity and not individual clinical sites.
The information from the returned
questionnaires was coded and data
were entered for analysis. The data
were checked for systematic e
ors
during routine data cleaning. When
esponse categories for data collected
in the UDS matched survey questions
exactly, missing data were imputed
from the 2003 UDS. The validity of
this imputation was supported by
comparison of 2004 survey data and
2003 UDS data for those items in
which the response categories were
identical, with survey results simila
for each category and around 10%
higher than UDS, consistent with the
1-year program growth. The source of
data on number of patient visits was
the 2003 UDS. Means were compared
using t tests, and proportions were
compared using �2 tests. All tests were
2 sided, and significance was set at
P�.05. Data analysis was performed
with SPSS statistical software version
11.5 (SPSS Inc, Chicago, Ill).
RESULTS
Location, Structure, and Staffing
The majority of CHCs (62.8%) in the
United States are funded as CHCs only
(TABLE 1). An additional 114 grantees
are funded as homeless centers (13.4%),
either as stand-alone entities or in con-
junction with CHCs. An additional 93
grantees (11.0%) are either migrant
health centers (MHCs) or a combina-
tion of CHCs and MHCs. The other 108
health centers represent institutions
with other funding combinations.
As a group, US CHCs are in the pro-
cess of expanding their capability of
providing services, with 66.3% of the
grantees planning to expand their op-
erations and 54.6% in the process of
adding new clinical sites (Table 1). Only
18.1% of the grantees replied that they
were planning to do neither.
One of the most important determi-
nants of the structure and function of the
CHCs is whether they are located in ru-
al or u
an areas. U
an grantees are
much more likely to receive their fund-
ing from categorical grant programs that
grew out of the initial CHC program;
46.5% of u
an grantees receive some o
all of their funding from the newer fund-
ing streams compared with 21.6% of the
ural grantees (P�.001). Rural CHCs
have a mean of 30.9 clinical full-time
equivalents (FTEs) compared with the
u
an CHCs, with a mean of 51.8 FTEs;
SHORTAGES OF MEDICAL PERSONNEL AT COMMUNITY HEALTH CENTERS
©2006 American Medical Association. All rights reserved. (Reprinted) JAMA, March 1, 2006—Vol 295, No XXXXXXXXXX
Downloaded From: http:
jama.jamanetwork.com/ by a Oklahoma State University User on 07/16/2014
ural centers serve a mean of 9921 pa-
tients and have a mean annual budget of
$ XXXXXXXXXX, compared with u
an grant-
ees who serve XXXXXXXXXXpatients and spend
$ XXXXXXXXXXper year.
The main objective of CHCs is the
provision of primary care services, and
their clinician mix reflects this mis-
sion (TABLE 2). Primary care physi-
cians comprise 89.4% of CHC physi-
cians. Family physicians are the single
largest category of specialists in both ru-
al and u
an centers, accounting fo
48.1% of the total physician staff. Ur-
an grantees employ more internists
and pediatricians, but even in these set-
tings the total number of family phy-
sicians equals the combined number of
internists and pediatricians.
Obstetrician/gynecologists and psy-
chiatrists represent less than 10% of the
CHC physician workforce and are more
likely to be found among u
an grant-
ees. There are few other specialty phy-
sicians; “other specialist physicians” ac-
count for only 2.6% of the total numbe
of physicians employed by the CHCs,
from the 2003 UDS. Of the grantees,
62.5% of those from rural areas and
28.8% of those from u
an areas em-
ploy only physicians from the 3 pri-
mary care fields.
The physician staff is comple-
mented by a substantial number of
primary care nonphysician clinicians,
epresented by nurse practitioners, phy-
sician assistants, and certified nurse
midwives. In rural CHCs, 46% of the
direct clinical providers of care are non-
physician clinicians compared with
38.9% in u
an CHCs. U
an grantees
are more likely to employ nurse prac-
titioners. The distribution of nurse mid-
wives is similar to that of obstetricians.
The CHCs have a large comple-
ment of registered nurses, with a mean
of 3.8 FTEs for rural grantees and a
mean of 5.7 FTEs for the u
an grant-
ees. Mental health clinicians and den-
tists are present in most of the CHCs;
the number of dentist FTEs in u
an
areas is almost twice that of their rural
counterparts. Pharmacists are com-
monly found in both settings.
Clinician Vacancies
Funded staff vacancies are common in
CHCs (TABLE 3). The greatest aggre-
Table 1. Structural Characteristics and Expansion Plans of Federally Funded Health Centers, by Grantee Type*
Grantee Type
No. of Clinical
Sites per Grantee,
Median (Range)
No. (%) Mean No. in 2003† Encounters
per FTE
Physician
in 2003†
No. (%)
Grantees
Survey
Response Rate Rural Patients Visits
Clinical
FTEs
Planning
to Expand
Operations
Planning
to Expand
Sites
CHC only XXXXXXXXXX XXXXXXXXXX XXXXXXXXXX XXXXXXXXXX XXXXXXXXXX)
CHC/MHC XXXXXXXXXX XXXXXXXXXX XXXXXXXXXX XXXXXXXXXX68.4)
Homeless only XXXXXXXXXX XXXXXXXXXX XXXXXXXXXX XXXXXXXXXX45.6)
CHC/homeless XXXXXXXXXX XXXXXXXXXX XXXXXXXXXX XXXXXXXXXX74.8)
CHC/school health XXXXXXXXXX XXXXXXXXXX XXXXXXXXXX XXXXXXXXXX79.4)
MHC only 6