Community Health Clinics Flourish, but Doctors Are Few (The Washington Post)

Government Needs to Entice Physicians, Health Officials Say

By Christopher Lee

The Bush administration has increased spending on community health centers by hundreds of millions of dollars since 2001, helping to open or expand more than 500 of the facilities and extending basic medical services to 4.5 million people.

But the promise of better health care for millions of Americans in underserved communities is being undermined by a chronic shortage of doctors -- one that some officials of the health centers say the administration has done too little to address.

Although the number of physicians employed by the centers has increased by 41 percent, to 7,320, under the federally funded expansion, many organizations have found it nearly impossible to land the primary-care doctors they need to match the growing caseload.

"At the same time you are building all these new buildings, and starting these organizations, you are not putting people in them," said Joe Liszak, chief executive of Community Health Services of Fremont, Ohio, a rural health center whose seven doctors cared for 10,000 patients last year. "It's like building a grocery store without having groceries."

In Ohio, the number of health centers rose from 107 to 122 between 2002 and 2005 -- a 14 percent increase, according to the Ohio Association of Community Health Centers. In the same period, the number of patients seen went up by 26 percent, to 325,000. But the number of physicians rose only 9 percent, from 163 to 177.

"It doesn't do us any good to open up new community health centers if we can't staff them," said Shawn Frick, the association's executive director. "We are getting to a point of desperation. . . . There is not a single state in the country that is not having a physician problem right now."

Administration officials say they are doing their part, increasing health center funding by $645 million (about 48 percent) since the beginning of the 2002 fiscal year. Much of the money goes to hire and pay medical professionals, said James Macrae, associate administrator for primary health care in the Health Resources and Services Administration.

"We have put a significant amount of money . . . to really support bringing physicians, nurse practitioners and certified midwives into underserved communities," said Macrae, whose agency is part of the Department of Health and Human Services. "At the same time, we also recognize that there is a need for getting more people interested in providing care to the underserved."

Health center officials are grateful for the money and the recognition of their role. But they say the shortage of primary-care physicians -- a national problem as many new doctors select more lucrative specialties -- is felt especially acutely in their communities.

The average health center has a family physician staff vacancy rate of more than 13 percent, according to a study published last year in the Journal of the American Medical Association. Those in rural areas have a vacancy rate approaching 16 percent, according to the study, which surveyed 846 health centers between May and September 2004. The shortage of dentists was even worse -- 18.5 percent overall, and 26.7 percent in rural communities.

Attracting physicians is easier in the Washington region, said local health center officials, but it is difficult to compete with private hospitals, which typically pay higher salaries.

"Where we have a real problem is with the nursing," said Jose Aponte, vice president for operations at Unity Health Care, which operates a network of 12 health centers serving more than 70,000 people in the District. "We try to keep our salaries competitive, but [with] bonuses and other issues, it's a lot easier for hospitals to do than it is for us."

Kristin Langlykke, executive director of Alexandria Neighborhood Health Services in Virginia, said the center gets good applicants but scrambles to find professionals with foreign-language skills. The center, which serves 11,000 patients in two locations, has the equivalent of three full-time physicians and five nurses, but it is looking for three more of each. Its doctors earn about $125,000 a year. Recruiting "is a challenge, and it takes time and effort," she said.

To cope, many centers rely heavily on the National Health Service Corps, a $126 million federal program under which newly minted doctors agree to work for a few years in underserved areas in exchange for partial repayment of their medical school loans. The centers also depend on foreign-born doctors who have completed their medical training in the United States, who can stay in the country for three more years if they agree to work in needy areas.

Still, that is not enough to fill the gap, said Dan Hawkins, policy director for the National Association of Community Health Centers. For lack of funding, the Health Service Corps had to turn away about half of the 1,800 doctors who applied last year, Hawkins said. He said the program needs at least $150 million next year -- and increases to bring it to $300 million within seven years -- but President Bush has proposed only $116 million for 2008.

"There is not a health center in the country that doesn't have more people coming in the doors than they can serve," Hawkins said. "They have waiting lists. . . . We need more access to care, which means we need more health center-type sites. But in order to do that, we need the resources -- and the clinicians."

Community health centers arose from President Lyndon B. Johnson's War on Poverty, in which the federal government helped set up neighborhood clinics in impoverished rural and urban areas. Today more than 3,800 of the nonprofit facilities provide basic health-care services to 15 million people, regardless of ability to pay. Patients are evenly split between rural areas and inner cities, according to the health center association. About 70 percent live at or below the poverty line, and three-quarters have no insurance or are on Medicaid.

Christopher Rural Health Planning, an Illinois health center 300 miles south of Chicago, has opened two new sites since 2005, bringing its total to 13 sites in nine counties. One new site, in Mount Vernon, Ill., has a pediatrician but needs a family-practice doctor and a dentist, said Executive Vice President Sally Cesar. The other, in Du Quoin, Ill., has a family practice physician but needs a nurse practitioner, she said.

Overall, the health center has 30 doctors, eight physician assistants and three dentists serving 29,281 patients, Cesar said. The pay is not bad; doctors earn $160,000 to $220,000 a year. Yet the center needs four more physicians and three more dentists, in part because newly opened sites must offer dental care, Cesar said.

"Everybody needs dentists," she said. "I'll take as many as you can get me. . . . What is so frustrating is that you can prevent so much of this tooth decay. It's just that there are not enough dentists to see everybody that needs to be seen."

In Georgia, Albany Area Primary Health Care has 20 full-time physicians and five physician assistants. But the health center needs at least three more of each to cope with the annual caseload of 27,000 patients, said chief executive Tary L. Brown.

"If you can't even employ a physician, then you are limiting the number of patients that can be seen," Brown said. "Ultimately, the access [to care] that they are going to take is through the emergency room, which is more costly."

Macrae, the HHS official, said the administration will continue to do the best it can to expand care through the health centers, including by forming partnerships with states and medical schools to entice doctors to work in them.

"The bottom line is we have been able to recruit physicians across the country to support this initiative," he said. "We've been able to continue to provide access now to almost 15 million people that wouldn't have access without the program. But are there cases and pockets where it's tough to recruit? Absolutely. And we're trying as best we can to provide the support and resources to help health centers and others be able to meet that need."