What Are Federally Qualified Health Centers Looking for in Their CEOs?

Julie Rosen, leader of executive recruiting firm WittKieffer's Not-for-Profit Practice, recently authored a report about building sustainable leadership in Federally Qualified Health Centers. She recently spoke with Healthcare Innovation about some of the report’s findings and her experience recruiting FQHC leaders. 

Before working at WittKieffer, Rosen served as executive director of the Schwartz Center for Compassionate Healthcare in Boston, a national not-for-profit organization advocating for enhancing the patient-clinician relationship. Prior to the Schwartz Center, she was assistant vice president for public and community affairs at Tufts Health Plan and executive director of the Conference of Boston Teaching Hospitals. She also served in leadership roles with the Massachusetts Hospital Association, Massachusetts Medical Society, and American Dental Hygienists’ Association.

In addition to surveying FQHC leaders for this report, WittKiefer also carried out proprietary research on the career paths of more than 350 FQHC CEOs across the country. 

Healthcare Innovation: I think most of our readers are aware of what FQHCs do, but what are some key challenges of being in the CEO position of an FQHC?

Rosen: It’s interesting that you say that most people know what FQHC agencies are. I know a lot of people in healthcare that have never heard of an FQ, which I find astounding, because so many people get their healthcare there now. 

There are more challenges around social determinants of health. A lot of these patients are at risk, underserved, and they have needs around transportation and economic security, food and environmental hazards like lead paint. There are a lot of non-English-speaking people. There are a lot of people that don't understand the healthcare system. So it’s a different population. It's a different payer mix, for the most part. It’s not purely healthcare — it's healthcare, but unless you provide all of those other services, you're not going to improve the lives of patients. 

The other thing that makes it different is that 51% of the boards of FQs have to be patients. 

When I do my searches, I insist that there are patient representatives, because that's the majority of the board. Board education is really important — making sure that everybody is on the same page, making sure that the board has enough information, and making sure that the board is representative.

HCI: In your research, did you find some common themes about the CEO demographics and academic backgrounds?

Rosen: It's interesting. A lot of the FQHC founders who are retiring are social workers who grew small community clinics. They started adding different physician practices, and then all of a sudden they had a $100 million operation. They picked up the business skills, and now the organization's ready for something different. A lot of the FQHCs did really well during the pandemic, because there was a lot of PPE money. They were flush, and now they're not. We see a lot of more turnaround situations. 

We place some CEOs who have never worked in an FQ environment. In California, we just placed a woman who was a Kaiser executive from a very large outpatient practice and who wanted to give back. We are seeing a lot of our older people with traditional healthcare careers who now want to give back. 

HCI: Do you see a lot of physicians stepping into that CEO role? 

Rosen: Yes. The first two FQ searches we did were in Massachusetts, and they were both MDs. At the FQHCs, there are often major clinician productivity issues. They join FQHCs because they want to do good work. They need more time with each patient because their patients are more complicated. And because of the payment incentive system, they've got to be more efficient, so there are issues about productivity and scheduling.

HCI: Your report found that there's been a 20% CEO turnover rate in the past two years. Are there some reasons why we're seeing this high turnover rate now?

Rosen: There are some reasons that are related to FQs, and there are other reasons that are more related to demographics. People retire, saying they’ve had enough. These searches are really hard. I mean, they're really gratifying, but they're really, really hard. Getting everybody on the same page is, is hard, because what the FQs want is an outstanding, strategic person who's a visionary, who’s great at operations and great at the clinical stuff, and great at finance, and can be an emissary for the organization. And, oh, by the way, raises money and has a ton of emotional intelligence. And they're only going to pay $250,000 or something like that.

HCI: The report also gets into whether they have succession planning in place and are starting to prepare people internally to move up into that CEO position. And it sounds like the report said that's not happening very often.

Rosen: That's right. The National Association of Community Health Centers (NACHC) does have some mentorship programs where older, retiring FQ CEOs mentor younger ones.

I come from the hospital industry originally, and there is a lot more success there in terms of succession planning. A  lot of these FQHC organizations are running by the seat of their pants, so they don't really have the resources to think about that. I think out of the 30 positions we’ve been involved with, maybe six or seven were filled by people who were coming up through the ranks.

HCI: Are we seeing more FQHCs getting involved in value-based care programs? And does that require an additional skill set on the part of the CEO? 

Rosen: Every FQ wants the CEOs to understand what value-based care is. I think it depends on the state and how many FQs there are and how sophisticated the state is in terms of its payment. We’ve done a ton of work in California and Massachusetts, and those are the more sophisticated states. But if you go to some other states, they’re just not quite as sophisticated. They're just getting into value-based care now.

HCI: Your report, says that workforce challenges include talent, attraction, retention and burnout. Are there some ways you've seen successful FQHC leaders deal with those issues?

Rosen: Usually by flexible scheduling. But coming back to what I said before about productivity, it's a huge issue. It's a real balancing act. There's also been real tension in the organizations between the administrative staff, especially during the pandemic, and the clinical staff, because the administrative staff didn't have to come in. They could work from home. This is kind of old news, but there’s still a lingering tension in some of the FQs between those who are on the front lines and those who are doing the billing and coding.

HCI: Is there anything else you want to mention? 

Rosen: Just that the FQs are great organizations. There are some really talented leaders out there. There are a lot of FQs that are getting into joint ventures with hospitals and partnerships around housing. I have done searches for homeless shelters that have FQs attached to them. So there are just a lot of different ways that FQs are springing up, and I think it's really the wave of the future.