Workforce Capacity in Federally Qualified Health Centers: Evidence of Shortages and Policy Implications

Abstract

The Health Center Program is a federally funded program authorized under Section 330 of the Public Health Service Act that supports a national network of approximately 1,400 Federally Qualified Health Centers (FQHCs) each of which provide care for medically underserved populations. Although the Health Center Program receives bipartisan support, this program remains situated within the contested U.S. healthcare policy landscape. As a result, FQHCs have been subject to both direct and indirect effects of healthcare reforms, which have weakened their operational capacity in recent years. At the same time, the U.S. is experiencing a nationwide shortage of healthcare workers. Given their current more precarious position, I hypothesize that FQHCs could be at a disadvantage in the increasingly competitive healthcare market, and they may be facing workforce shortages. Furthermore, I hypothesize that workforce capacity is influenced not only by factors that are intrinsic to FQHCs but also the broader healthcare environment in which they operate. This thesis employed mixed methods. To quantify the workforce capacity in FQHCs, I collected original data through a survey sent to all health center asking them to report their current number of full-time positions (FTEs) and their clinical vacancies for both physicians and advanced practice providers (APPs). Respondents were also asked to rank the challenges they are facing with regards to recruitment and retention for each provider type using a Likert scale. I then conducted statistical analyses and modeling to identify associations and predict the total number of nationwide shortages in FQHCs. To gain a deeper understanding of the workforce capacity in real life and the driving factors contributing to provider shortages, I conducted interviews with 24 participants at health centers across the country. I performed reflexive thematic analysis to identify key themes from these conversations. The findings indicate an estimated nationwide shortage of 2,914 physicians (95% CI: 2,799–4,236) and 3,216 advanced practice providers (APPs) (95% CI: 2,763–4,767) across FQHCs. Among the surveyed population, the average workforce shortage was 20.68% for physicians and 12.76% for APPs. Shortages were significantly associated with health centers serving higher proportions of uninsured and low-income patients. Interviews revealed that those health centers experiencing the most severe shortages were approaching a critical threshold in terms of the sustainability of their operations. Key factors limiting workforce capacity included the inability to offer competitive compensation, an inadequate training pipeline, and difficulty serving the patient population. Conversely, mission alignment and the positive work environment were identified as factors that strengthened workforce capacity. Three policy recommendations are proposed, informed by a review of the literature and interviews with health administrators. First, Congress should consider revising the funding mechanism to provide stable funding through 10-year cycles under the federal mandate. Second, a standardized national residency and training program should be established specifically for FQHCs. Third, demonstration projects should be implemented to transition from a prospective payer model to a value-based care model. Each of these solutions addresses different factors contributing to workforce shortages and they are reasonably feasible within the current healthcare policy landscape.