Take II: Factors Related to Recruitment and Retention
of Primary Care Physicians at Community Health
Centers post MA Health Care Reform:
Results from 2008 and 2013
Statewide Physician Surveys
APHA Annual Meeting
New Orleans, LA
November, 2014
Judith A. Savageau, MPH
UMass Medical School
Presenter Disclosure
No members of the project team have any
relationships to disclose
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Project Team
• MA League of Community Health Centers (MLCHC)
– Joan Pernice, Leslie Bailey
• MassAHEC Network, UMass Medical School (UMMS)
– Linda Cragin
• UMMS Department of Family Medicine & Community Health
– Warren Ferguson
• UMMS Center for Health Policy and Research (CHPR)
– Judy Savageau, Laura Sefton
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Background and Significance
Health care reform, in Massachusetts and nationally, has
increased the number of patients utilizing public or private
health insurance to seek care.
• Newly-insured patients are expected to continue to seek
care in Community Health Centers (CHCs), which act as
medical homes for underserved or uninsured populations ,
offering a range of, and easy access to, high-quality
coordinated services in one setting.
• Existing and predicted shortages of primary care providers
(PCPs) in an environment of rising need will reduce access
for vulnerable populations.
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Background and Significance
Training and preparing medical students and residents to be
PCPs skilled in providing culturally-appropriate care to
underserved populations has never been more important.
• CHCs find it challenging to recruit and retain physicians,
leading to staff shortages.
• Primary care training in a CHC prepares students and
residents to work with vulnerable populations, increasing the
likelihood of practicing in a CHC setting.
• Insights into the values of the current CHC PCP workforce can
guide educational priorities.
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Study Objectives
• In 2008, UMMS, MassAHEC, and MLCHC surveyed CHC PCPs
to:
– characterize the workforce;
– identify factors related to preparedness, recruitment and
retention; and
– correlate satisfaction with organizational improvement
efforts.
• Survey repeated in 2013 to determine the impact of
Massachusetts health care reform.
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Methods
• Sample frame: 2013 list from MLCHC members (N=677
providers with email addresses)
• Mailing intended to survey primary care physicians only
(excluded: residents, PAs, NPs and specialists)
• Emailed link with URL to SurveyMonkey web-based survey to
all providers with…
– 2 email reminders to physicians
– final follow-up reminder to CHC Medical Directors from the
MLCHC
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Methods
• 30-item survey:
–
–
–
–
–
–
–
–
Physician demographics and practice characteristics
Medical education and residency training
Past and current participation in loan repayment programs
Preparedness to practice in a CHC
Factors related to the process of selecting a CHC practice setting
Satisfaction with current practice arrangement
Retention strategies within the CHC
Future practice plans
• New questions added to baseline (2008) survey, e.g.:
– integrated care
– multidisciplinary team-based care
– language competencies
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Methods
• Data analysis: SAS V9.13; univariate, bivariate and multivariate
statistics computed
• Factor analyses used to create domain scores
• for example… compensation/benefits pkg/CMEs;
opportunities to do QI/administration/project leadership;
and patient diversity/CHC mission
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Results – Response Rates
• Response rate in 2008: 58% (294/505)
• Responses received from providers at 46 CHCs
• Response rates per CHC ranged from 29% - 100%
• Response rate in 2013: 48% (301 of 629 usable surveys)
• Responses received from providers at 44 CHCs
• Response rates per CHC ranged from 8% - 100%
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Demographic and Practice Characteristics
Table 1. Frequency, percent distributions and descriptive statistics of study sample
sociodemographic and practice characteristics; N=301, 2013.
Study Sample*
n (%)
Sociodemographic Characteristics
Gender
Male
106 (38.3%)
Female
171 (61.7%)
Age group
Under 40 years
78 (30.4%)
40-49 years
79 (30.7%)
50-59 years
59 (23.0%)
60+ years
41 (16.0%)
Range
30-79 years
Mean (SD)
46.9 (10.8)
Years in practice
Less than 10 years
103 (39.0%)
Less than 5 years
[58; 22.0%]
5-9 years
[45; 17.0%]
10+ years
131 (61.0%)
Range
<1-51 years
Mean (SD)
14.9 (11.1)
Race
White
193 (70.2%)
Non-White
61 (22.2%)
Decline to state
21 (7.6%)
Ethnicity
Not Hispanic or Latino
230 (83.3%)
Hispanic or Latino
27 (9.8%)
Decline to state
19 (6.9%)
Number of non-English languages spoken in clinical practice
0
80 (26.6%)
1
148 (49.2%)
2
48 (15.9%)
3+
25 (8.3%)
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Demographic and Practice Characteristics
Practice Characteristics
CHC Region of Massachusetts
Boston
165 (54.8%)
Northeast
61 (20.3%)
Southeast
19 (6.3%)
Cape/Islands
11 (3.7%)
Central
28 (9.3%)
West
17 (5.6%)
Specialty
Family Medicine
121 (40.9%)
Internal Medicine
99 (33.4%)
Pediatrics (including Med-Peds)
67 (22.6%)
OB/GYN
9 (3.0%)
Year of hire at current CHC
< 5 years ago
104 (35.9%)
5+ years ago
186 (64.1%)
< 10 years ago
168 (57.9%)
10+ years ago
122 (42.1%)
< 20 years ago
245 (84.5%)
20+ years ago
45 (15.5%)
Current employment status
Part-time at this CHC (< 25 hrs/wk)
91 (30.6%)
Full-time at this CHC (25+ hrs/wk)
206 (69.4%)
Visa/Loan repayment program participation
None
161 (53.5%)
1 current/former participants
114 (37.9%)
2+ current/former participants
26 (8.6%)
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Provider / Practice Characteristics
MLCHC MD Survey - 2008/2013
Age
100
% Responding
80
60
40
34
37
30
31
23
21
16
20
8
0
Under 40
*p<.10; ***p<.01
40-49*
2008
50-59
60+***
2013
In 2013, MD ages ranged from 30-79 yrs (Mean: 47 yrs).
Older PCPs were significantly more likely to be: working PT, non-FM MDs, white,
and at their current CHC more than 10 yrs. Age was not significantly associated
with provider gender.
Source: Statewide Surveys of PCPs in MA CHCs: October, 2013; N=301 and May, 2008; N=294
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Provider / Practice Characteristics
MLCHC MD Survey - 2008/2013
# of Languages Spoken
in Addition to English
100
% Responding
80
60
49
46
40
39
27
20
16
12
8
4
0
None****
****p<.001
1
2008
2
3+
2013
In 2013, one-half of respondents speak 1 additional non-English language, and
24% speak 2+ non-English languages. PCPs in 2013 were significantly more likely to
speak additional non-English languages compared to respondents in 2008.
Source: Statewide Surveys of PCPs in MA CHCs: October, 2013; N=301 and May, 2008; N=294
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Provider / Practice Characteristics
None
27%
Spanish
63%
Portuguese
9%
French
6%
Hindi
5%
Haitian Creole
5%
Arabic
4%
Cape Verdean
4%
Vietnamese
3%
Chinese
2%
Urdu
2%
Russian
2%
Gujarati, Khmer, Korean
<1%
In 2013, 86% of MDs with foreign language skills reported
speaking Spanish fluently enough to conduct a new patient
history and physical exam with a patient compared to 76%
in 2008.
• MDs in the < 40 yrs and 50-59 yrs age groups were more
likely to report speaking 1 additional non-English
language. However, providers 40-49 yrs were significantly
more likely to report speaking 2+ additional non-English
language.
• Female providers were more likely to speak 1 additional
language while male providers reported speaking 2+
additional languages.
• White providers were more likely to speak 1 additional
language while non-white providers were significantly
more likely to report speaking 2+ languages.
• Hispanic providers were significantly more likely to report
speaking 1 additional non-English language.
Source: Statewide Surveys of PCPs in MA CHCs: October, 2013; N=301
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Preparedness Following Residency Training
MLCHC MD Survey - 2008/2013
Extent Prepared to...
% Responding 'Very Prepared/Prepared'
100
87
82
80
80
75
73
76
72
66
65
69
60
40
20
0
Work w/ Undrsrvd Practice in a CHC**
Populations**
**p<.05
Work w/
MassHealth Ins**
2008
Work as Multidisc
Team Member
Work w/ NonEnglish Patients
2013
Compared to 2008, PCPs responding in 2013 rated themselves as being
significantly more prepared to practice in a CHC, work with underserved
populations, and work with MassHealth insurance.
Source: Statewide Surveys of PCPs in MA CHCs: October, 2013; N=301 and May, 2008; N=294
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Factors Related to Recruitment
MLCHC MD Survey - 2008/2013
Important Factors in Selecting a CHC
100
89
89
% Responding
80
63
60
60
52
52
40
21
24
20
20
10
0
Serve
Specific
Geographic
Region
****p<.001
Live Near
Family
Work for
Org/Mission
I Believe In
2008
Serve at Serve Loan
Familiar Site Oblig****
2013
Of comparable questions asked in both 2008 and 2013, only ‘I needed to serve out
a loan/visa obligation’ was significantly different (higher) in 2013 among factors
important to PCPs in their initial considerations of working in a CHC.
Source: Statewide Surveys of PCPs in MA CHCs: October, 2013; N=301 and May, 2008; N=294
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Interviewing Factors Important in Hiring
MLCHC MD Survey - 2008/2013
Important Factors in Hiring Process
% Responding 'Very Important/Important'
100
93
87
84
88
80
80
79
55
60
40
34
26
19
20
0
Site met prof
needs***
*p<.10; **p<.05; ***p<.01
Pt community
served*
Interview w/
clinical team
2008
Touring
community***
Accepted loan/visa
prog**
2013
Compared to 2008, PCPs were significantly more likely to rate ‘meeting professional
needs’, ‘understanding community of pts to be served’ and ‘acceptance of loan/visa
program’ as important in the interviewing process. However, touring the CHC’s local
community/neighborhood was significantly less important to PCPs in 2013.
Source: Statewide Surveys of PCPs in MA CHCs: October, 2013; N=301 and May, 2008; N=294
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% Responding 'Very Important/Important'
Factors Important to Joining CHC
MLCHC MD Survey - 2008/2013
Important Factors for Joining Current Practice
100
80
60
90
89
87
79
73
78
77
50
75
78
72
69
58
52
60
54
40
32
26
25
20
23
26
20
0
*p<.10; **p<.01; ***p<.001
2008
2013
Among the many differences between 2008 and 2013, the most significant
increases in importance of factors related to joining their current CHC were
‘benefits package’, ‘continuing medical education benefits’, and ‘total
compensation’.
Source: Statewide Surveys of PCPs in MA CHCs: October, 2013; N=301 and May, 2008; N=294
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% Responding 'Very Satisfied/Satisfied'
Satisfaction with Current Practice
Arrangement
MLCHC MD Survey - 2008/2013
Satisfaction with Factors for Joining Current Practice
100
82
88
82
81
80
61
69
63
61
60
52
60
43
63
57
56
42
41
40
47
54
50
45
36
20
0
*p<.10; **p<.05; ***p<.01; ****p<.001
2008
2013
Similar to factors important in joining their current CHC, PCPs in 2013 were
significantly more satisfied with many factors compared to 2008; key among them
were ‘benefits package’, ‘CME benefits’, ‘total compensation’, and ‘opportunities
to participate in research’.
Source: Statewide Surveys of PCPs in MA CHCs: October, 2013; N=301 and May, 2008; N=294
20
50
% Responding 'Very Important/Important'
Retention Factors Identified as Important
MLCHC MD Survey - 2008/2013
Factors Important to Continuing CHC Practice
100
94 94
85
90
82 84
80
80 82
75 75
74 75
75
65
61 63
60
68
61
62
54
55
56
48
43 43
41
32
40
31
21 22
20
0
*p<.10; **p<.05; ***p<.01; ****p<.001
2008
2013
Many factors were deemed ‘important’ by MDs – some increasing in importance from
2008 to 2013 and some decreasing in importance. Among those of significance in
increased importance was: ‘support staff or other operational support’. Of significance
in decreased importance was ‘addition or increase in mid-level providers’. ‘pension plan
availability’, and ‘flex-time/job sharing’.
Source: Statewide Surveys of PCPs in MA CHCs: October, 2013; N=301 and May, 2008; N=294
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Provider Retention in Five Years
MLCHC MD Survey - 2008/2013
Status in 5 Years
100
90
92
% Responding 'Very Likely/Likely'
90
87
85
83
84
80
66
70
64
66
63
60
50
40
32
36
30
15
20
16
7
10
8
5
9
0
Remain in
current
discipline
**p<.05
Continue work Remain in MA
w/ undrsrvd
pop
Remain in
present CHC
Remain in any
CHC
2008
Move to CHC
leadership role
Move to
Move to
research or private practice
admin
Retire**
2013
There were few differences in planning for the next 5 years between the 2 study
cohorts. Only intent to retire was significantly higher in 2013 compared to the
2008 group of MDs.
Source: Statewide Surveys of PCPs in MA CHCs: October, 2013; N=301 and May, 2008; N=294
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Multivariate Models Predicting Likelihood of Continuing
to Practice in a CHC in Next 5 Years
Multivariate (mixed-method) regression models run for:
• All participants
• All participants, excluding those most likely to retire in next 5
years
• All participants, excluding those most likely to retire in next 5
years and 60+ years of age
• Participants in current practice < 10 years vs 10+ years
• Participants in current practice 10+ years, excluding those 60+
years of age
• Participants in Boston-based vs non Boston-based CHCs
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Multivariate Models Predicting Likelihood of Continuing
to Practice in a CHC in Next 5 Years
Mixed model regression results assessing factors important to PCPs remaining in a CHC clinical
setting in the next 5 years – Total Population, N=301, 2013.
Independent variables
Beta estimate (SE)
p value
Age group
< 40 years
2.3014 (.7781)
.0035
40-49 years
1.8884 (.5944)
.0017
50-59 years
2.2513 (.5926)
.0002
60+ years
Referent group
Years out of residency training
< 10 years
-1.5249 (.5852)
10+ years
Referent group
.0098
Speak additional Non-English languages in practice
0 additional languages spoken
-0.7955 (.4065)
1+ additional languages spoken
Referent group
.0531
Research and teaching opportunities as an important
factor when first considering CHC practice (lower score
= greater importance)
-0.2340 (.0848)
.0069
Compensation as an important factor when making
decision to join CHC (lower score = greater
importance)
0.1784 (.0719)
.0139
Satisfaction with CHC model of care and morale of
colleagues at current CHC practice (lower score =
greater satisfaction)
-0.1612 (.0768)
.0375
Satisfaction with recognition and mentoring at CHC
practice (lower score = greater satisfaction)
-0.1459 (.0508)
.0045
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Multivariate Models Predicting Likelihood of Continuing
to Practice in a CHC in Next 5 Years
Overall, physicians who were more likely to report intent to
remain in a CHC environment were more likely to:
•
•
•
•
be younger;
be in practice for 10+ years;
speak at least one non-English language;
report greater importance for research and teaching opportunities
when first considering the CHC as a practice setting;
• report less importance regarding compensation when making the
decision to join their current CHC;
• report increased satisfaction with the CHC model of care and the
morale of their colleagues; and
• report increased satisfaction with recognition of their professional
development, clinical practice goals, and overall work (plus having a
mentor and receiving regular feedback).
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Limitations
• Self-reported information; potential under- or over-reporting
of perceptions of preparedness for practice, importance of
recruitment strategies, satisfaction with current practice,
anticipated changes in practice, etc.
• ~ 50% response rate; limited data to assess non-response bias
• One state: MA; may not be generalizable
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Discussion
• When asked, in an open-ended fashion, whether there were
any additional comments the PCP would like to share with use
about recruitment and/or retention issues, the many
comments (n=70) received were grouped into several
categories:
Administration
Compensation and Benefits
Workload
Loan repayment
Mission
CHC structure and systems
Support staff
Resources
Lifestyle
Professional development
Morale
Residency training
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Discussion – Provider Quotes Regarding
Recruitment/Retention
• [PREPARATION] “I think exposure to primary care and CHC
settings need to start earlier in a person's medical career. We
need more exposure to CHC settings for medical students and
residents, more participation for residents with QI projects at
CHC and exposure to medical home/team-based care
initiatives - so students and residents can see how rewarding,
challenging and exciting it is to practice primary care at a
CHC. Students and residents see so easily how exciting the
hospital is and we need to infuse the same experience at
CHCs.”
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Discussion – Provider Quotes Regarding
Recruitment/Retention
• [RECRUITMENT] “I fulfilled a four-year NHSC scholarship
obligation at a CHC in [another state]. That experience nearly
burned me out and I left for private practice... I am now once
again working at a CHC because I believe in the mission and I
desire to work with the underserved. My current practice is a
much saner place - the workload is more reasonable and I'm
working part-time and creating my own work-life balance. I
still haven't decided if I'll remain here...my next move may
very well be to leave medicine entirely.”
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Discussion – Provider Quotes Regarding
Recruitment/Retention
• [RETENTION] “After working 20 years for the same CHC, I
think there are many dedicated, extremely bright and talented
physicians and compensation and lack of good support make
retention an ongoing difficult problem. I think that if
compensation cannot be better, then efforts should be made
to make support better so that a choice to work in a CHC can
offer good support and the perk of a good work/home life
balance.”
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Conclusions
Outcomes from 2008 and 2013 indicate opportunities to better
prepare medical students and residents for careers in CHCs and
recruit, retain and replace this vital and aging workforce.
• Exposure to CHCs during and throughout training fosters
social commitment.
• Physician success, i.e. their retention, is dependent upon a
competent, interprofessional clinical support team.
• A menu of options – teaching, policy and procedure
development, research, etc. also contributes to retention.
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Commitment is Not Enough
While commitment to underserved populations served by CHCs
is strong, equally important is:
• maintaining a work/life balance;
• professional development in light of new models of
interprofessional care; and
• addressing compensation.
To attract and maintain younger physicians as older physicians
retire will be challenging as overall fewer young physicians are
choosing primary care.
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Impact of MA Healthcare Reform
• In a state with a media-purported large supply of primary
care physicians, health reform has come to demonstrate a
clear imbalance of primary care access.
• As the main provider of the medical home for
Massachusetts underserved and uninsured individuals,
CHCs are at the forefront of health reform implementation;
its success or failure is partly dependent upon CHCs’ ability
to meet the rising need for health services for the newly
insured.
• The recruitment and retention of primary care physicians
has never been more important!
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And in closing…
“For me, the most important things are that the board is over
half patients and also the mission, and flexibility of schedule
and work type. Over the years, I have been privileged to have
had the opportunity to do clinical work, then administrative
and teaching work as well, and now am back to mostly clinical
work. What a place! All sorts of things to do, and a lot of
sensitivity to the life needs of the clinicians as well.”
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Contact Information
For more information, please contact either:
Judy Savageau, MPH
[email protected]
(774) 442-6535
Linda Cragin, MS
[email protected].
(508) 856-4303
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