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    Christian Green
    Christian Green, MA

    Throughout the COVID-19 pandemic, the exodus of staff and providers has been one of the top challenges for medical group practices. Perhaps no position represented the direness of the situation more than medical assistants (MAs), who often left for jobs outside healthcare.

    Despite a projected employment growth rate of 18% from 2020 to 2030,1 there has been a significant decline in the number of MAs since 2014 due to a number of factors, including reduced enrollment and school closures. Couple this with the ability to make more money at less stressful jobs, and practices were left scrambling to fill open positions with a less-than-ideal candidate pool. 

    According to a recent study in JAMA Health Forum, turnover rates surpassed 6% for medical aides and assistants from April to December 2020. Although turnover rates declined from January 2021 to October 2021, in early 2022, they were still 1.3% higher than the year-long period leading up to the pandemic.2

    Another study showed that the cost of turnover for each MA is $14,200, which translates to about 40% of their annual salary.3 Given the competition for MAs and subsequent shortage of talent, the cost of turnover likely has increased, with more time and effort required to recruit new hires.

    During the past 14 months, two MGMA Stat polls took a deeper dive into the lack of qualified MA candidates and the pressure it places on other MAs, providers and practices to fill the void. A May 4, 2021, MGMA Stat poll revealed the strain of finding qualified MAs. In that poll, 88% of practices said they had difficulty recruiting MAs.4 At the time, respondents noted:

    • “Either [candidates] are registered nurses, which is a higher educational level than we need, they don’t want to work, or they just don’t have the aptitude to learn. We have had to resort to hiring students trying to work around school schedules.”
    • “There are far fewer qualified candidates applying for openings. We are considering training staff for MA roles that do not have trade school certificates.”
    • “Most [candidates] are not well trained. We resorted to going straight to training schools; offering externships and training to keep the best teachable students; [then] offering jobs upon graduation … to keep them motivated to do well in their schooling. Still, we end up training them over again when they start with us.”

    Moreover, according to an April 5, 2022, MGMA Stat poll, 44% of respondents said MAs were the most difficult position to fill.5 In that poll, respondents encapsulated what’s all too real for practices, with inefficiency, reduced patient access and compensation challenges leading to low morale, stress, burnout, and departure, which makes a challenging situation even more difficult for practices. Responses included:

    • “There’s a much larger workload on existing MAs, and it’s much more costly to hire and keep current employees.”
    • “We’ve had to schedule less patients overall because we do not have enough support staff to treat them efficiently and effectively.”
    • “There are overtime costs; MAs working with more than one provider; morale issues; increased sick call-ins.”

    As practices continue to move toward patient-centered care, which emphasizes a team-based care model, the need for MAs will continue to increase. In fact, rather than the traditional ratio of one MA or less to one physician, the ratio is likely to increase to 2:1 or even 2.5:1.6 

    Facing this shortage of MAs, one healthcare system in North Carolina took matters into its own hands by cutting out the middleman and creating its own pipeline of recruits.

    Where are the viable candidates?

    An MGMA Better Performer in Operations, Cone Health is a private, not-for-profit healthcare system, founded in Greensboro, N.C., in 1953. Serving the people of Alamance, Forsyth, Guilford, Randolph, Rockingham and surrounding counties, the healthcare system has 550 physicians, 300 advanced practice providers (APPs) and 1,800 staff in more than 100 locations. It currently has 280,000 patients, with a million visits per year.

    During the past couple years, Cone Health struggled to find certified medical assistant (CMA) candidates to interview. According to assistant director Sally Hammond, some CMAs in the healthcare system left because of vaccine mandates or higher paying jobs. “People also just got tired of working,” Hammond said. “Then the staffing crisis came up, and what we were paying the starter CMA, they could go to Amazon and get at least that much, if not more.”

    Furthermore, fewer would-be CMAs are choosing healthcare when they reach community and vocational colleges. “The schools in our area … used to have maybe 30 students coming out every six months,” Hammond said. Since COVID-19, that number is closer to eight.

    Cone Health also competed with several major academic hospitals and other medical group practices for a small candidate pool, which made it even more difficult to hire for open CMA positions during the pandemic.

    Investing in CMAs

    Cone Health considered several tactics to improve recruitment and retention of CMAs — including adjusting salaries, covering recertification, and supporting CMA governance — with the intent of addressing a common complaint brought forth by CMAs: There was no upward mobility.

    Hammond often heard CMAs say, “I would love to be a practice administrator, but the gap between being a CMA and a practice administrator is so far, I don’t even know how to get there.” In response, Hammond and her staff developed a path forward, via a tiered approach. At each step, CMAs would take on more responsibility and add tasks to their daily duties. If a CMA wanted to become lead or supervisor for a team or for one of the system’s practices, the healthcare system would create a path. 

    To clearly delineate the path, Hammond said Cone Health established markers that, once hit, triggered a pay increase for CMAs, helping to show that the healthcare system was invested in their career advancement. This helped Cone Health compete with other health systems, as CMAs were getting $4 more an hour with some organizations. In total, the healthcare system invested $8 million in salary adjustments for CMAs. “We had to do it because … we were not competitive,” explained Hammond. “We were competitive at the end of the [salary] grade, but the start of the grade was just way too low.”

    Although Hammond noted that Cone Health was seeing great progress with this program, the administration decided to restructure positions, which put a hold on the tiered approach. “I feel like we lost some people [during this time], but that was just in reading online reviews,” Hammond said. “Allowing CMAs the ability to grow within their scope of knowledge within a tiered structure was vital to their success.”

    Covering recertification fees is another area of retention Cone Health focused on, which, according to Hammond, should be approved by the administration soon. “Whatever accreditation body they come out of … some of them are every five years and some are every two or three,” Hammond said, noting that it’s not costly and would go a long way in helping to keep CMAs.

    Also during this time, Hammond started asking for feedback from CMAs to determine what was important to them. First and foremost was a governing council, so CMAs began meeting quarterly to discuss their concerns and provide actionable information for system leadership.

    All this helped contribute to CMAs feeling valued, which was important to Hammond and Cone Health. “They’re probably the most valuable position we have,” maintained Hammond. “They really felt like they didn’t have a voice or the ability to improve their lot or talk about their struggles with each other, so we’ve tried to provide avenues for that.”

    Retention strategies at Cone Health

    At Cone Health, CMAs aren’t the only position the healthcare system is focusing on for long-term sustainability. During the pandemic, retention rates were also low for nurses and phlebotomists; however, Hammond pointed out that the issue was primarily in the system’s hospitals due to longer hours. “I think an RN who wants to work in a practice and values the hours — and not being on the floor in a hospital — usually knows that’s a pretty good deal,” she explained. 

    To help retain providers, Hammond said Cone Health increased wages, sign-on bonuses and retention bonuses, largely across the board for clinical positions. These tactics are in line with an April 12 MGMA Stat poll7 in which 56% of respondents said raising wages has been their primary strategy for addressing staffing issues.

    Despite these measures, Hammond noted that Cone Health was forced to bring on travel nurses on the hospital side, but due to the exorbitant pay rates, the organization is now looking into recruiting international nurses. “We are still struggling and trying to get out of the travel nurse thing. … It’s just been a nightmare,” she said.

    As Cone Health attempts to move away from travel nurses and their hefty salaries, the healthcare system has also implemented an internal travel nurse model. According to Hammond, Cone Health is paying a premium for its nurses to work shifts throughout the healthcare system at understaffed clinics. As an added incentive, the organization is also giving nurses more time off.

    Another tactic Cone Health has employed is compensating nurses for their schooling, based on years of service, so they can become nurse practitioners (NPs) or earn their doctorate of nursing practice (DNP). As with their CMAs, Cone Health is moving toward a tiered system that helps nurses obtain the skills they need to move up the career ladder, while earning more money each step of the way.

    Regardless of the position, Cone Health has endeavored to provide growth opportunities for providers and staff by listening to their needs. “[We want] to make sure they feel that they have a voice,” Hammond asserted.

    Establishing an employer-based training program

    The aforementioned investments helped Cone Health retain and bring on some CMAs, but the pipeline started to run dry, particularly amid the pandemic. Cone Health had long relied on nearby community colleges and technical schools to fill open CMA positions, but with turnover rates of more than 20%, the organization needed a new solution.

    As Hammond and her team looked for answers, they opted to replicate a program another system created through the National Healthcareer Association (NHA) to obtain educational and testing material for MA certification.

    When Cone Health started its CMA academy in fall 2021, students were in class for the first six months and then worked in the clinic for the second part of the yearlong program. There were six students in that first class, all of whom were invaluable contributors, according to Hammond. “I don’t know what we would have done without the six students,” Hammond said. “They had learned enough during our staffing crisis … that we were able to deploy them into the practices and they could room patients and those type of things.”

    Hammond added that on-the-job training helped make the CMA students comfortable with the work they would be doing once they earned certification. An additional benefit of in-house CMA development is that the organization can ensure that training is aligned with its initiatives and best practices, not to mention providing a high return on investment. 

    With a year of experience under its belt running its own academy, Cone Health decided to double the size of its next CMA class. The health system will also combine classroom and clinic work into a six-month training program, so students can become full-time CMAs in short order.

    Due to interest in the CMA academy, Hammond noted that Cone Health hasn’t had to look beyond its current employees to fill spots in the program. “The front office folks see this as a great opportunity to move up,” she said. “[Some] really wanted to be a CMA, but they had childcare issues or financial issues.”

    At less than $300 per student for materials and testing, upfront costs are minimal. However, the healthcare organization has to supply clinical trainers to instruct the CMA students. For Cone Health, compensating clinical trainers is a small price to pay for providing stability to the clinical department. “They sign a commitment to stay with Cone Health for two years as a CMA,” Hammond said, adding that she believes “it will keep them even longer than that because they feel invested.”

    Fortunately, Cone Health had two providers who jumped at the chance to offer their clinical expertise in the role of clinical trainer. As Hammond recounted, one of them was working in the organization’s quality department, while the other was the lead registered nurse (RN) in one of Cone Health’s practices. They both received their master’s in nursing education, so they already had a background in clinical instruction.

    “We were very blessed being in a health system,” Hammond said. “We probably had more of an opportunity to find folks who would like to do this kind of work.”

    Another key point Hammond made was that many of the community colleges and technical schools Cone Health worked with aren’t providing the clinical training CMAs need; they are simply providing theoretical knowledge as part of the curriculum. This often forced Cone Health to retrain their CMAs — for example, in taking blood pressure and administering shots — but Hammond is confident that won’t be the case going forward.

    “I have a feeling that these students will be better prepared than a lot we’ve gotten,” Hammond said of their in-house trained CMAs. “[Previous external hires] may have passed the certification exam, but their competencies were very low.”

    Hammond added that Cone Health will still have to take some CMAs from the outside, because the system is so large. “We always run between 30 and 60 CMA vacancies … a lot of that isn’t necessarily that we’re losing them, but we have new practices being built or we’re working through team care,” she said.

    For Cone Health, the CMA academy and its other retention strategies have already paid significant dividends: “We’re running at about a 10% turnover rate now,” Hammond said, noting that everyone is very excited about what lies ahead.

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    1. BLS. “Medical Assistants.” Occupational Outlook Handbook. Available from:
    2. Frogner BK, Dill JS. “Tracking Turnover Among Health Care Workers During the COVID-19 Pandemic.” JAMA Health Forum. 2022;3(4):e220371. doi:10.1001/jamahealthforum.2022.0371.
    3. Friedman JL, Neutze D. “The Financial Cost of Medical Assistant Turnover in an Academic Family Medicine Center.” J Am Board Fam Med. May-Jun 2020;33(3):426-430. doi: 10.3122/jabfm.2020.03.190119.
    4. Harrop C. “MAs MIA? The COVID-19 pandemic made hiring medical assistants harder than ever.” MGMA. May 6, 2021. Available from:
    5. MGMA staff members. “Medical assistants remain elusive for practices navigating a staffing crisis.” MGMA. April 5, 2022. Available from:
    6. National Healthcareer Association. “How to Win the Recruitment and Retention Battle for Medical Assistants.” Aug. 21, 2021. Available from:
    7. MGMA staff members. “In a tight market for talent, medical groups are raising wages to sustain their workforce.” MGMA. April 12, 2022. Available from:
    Christian Green

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