The Financial Cost of Medical Assistant Turnover in an Academic Family Medicine Center

Discussion

In our clinic in 2017, the MA turnover rate was 59%. This turnover rate is relatively similar to other published clinic staff turnover rates in similar settings,^14,15 although higher than Jones'¹⁸ estimate of nursing turnover rate of 19.4%. In calculating our turnover rate, we establish a baseline by which to compare future rates within our own clinic as well as a potential benchmark for similar clinics to use in addressing their own turnover. We also describe a method that other clinics can replicate and adapt to calculate their own turnover rates and costs.

The cost of MA turnover in our clinic in 2017 was $213,000, or $14,200 per MA, which is approximately 40% of the average annual salary of MAs working full time. In contrast, in a 2012 review of 11 studies on employee turnover, the Center for American Progress found that it costs businesses approximately 20% of a worker's salary to replace them.²⁰ This difference may, in part, be due to the prolonged training time MAs must complete to be competent in a wide range of areas, relative to employee training in other fields and, perhaps, MA training in other clinics and specialties. In our clinic, MAs train in both “front-desk” duties like taking insurance and copayments as well as more traditional tasks. They complete approximately 3 months of full-time, paid training before they work independently; this is consistent with the Bureau of Labor Statistics' description of MA training duration.⁸ As such, training accounted for over 70% of costs. Moreover, our total per employee cost was higher than the value ($4000–$11,000) Waldman et al.¹⁵ calculated for allied health workers at an academic medical center in 2010. Differences may reflect geographic differences in salaries and costs, as well as mild contributions from inflation. However, it is more likely due to methodological differences; although Waldman et al.¹⁵ were able to account for the lesser effectiveness of new hires, it is not clear that they accounted for the indirect cost of the time administrators and managers spend hiring, training, and terminating employees. Our per employee cost is lower than the $62,100–$67,100 Jones¹⁸ estimated for nurses in the United States, despite a higher turnover rate, likely owing to the lower average salary of MAs relative to nurses as well as the highest cost category of nurse turnover being related to filling vacancies ($48,300) rather than training ($5300).¹⁸

When adapting the NTCCM, we experienced greater challenges than initially anticipated in collecting the data to calculate the turnover rate and costs. MA hiring and training occur at both the health system and clinic level, and multiple clinic and health system administrators are involved in processes related to MA turnover. In our model, we balanced a desire for precision with the reality that most of the data we sought were not readily available and existed primarily as averages and estimates.

Our study had multiple methodological limitations, including the use of self-reported estimates to determine the cost of administrator/manager time in turnover. If this element were completely removed from the calculation, total cost of MA turnover would remain high at $135,000, or $9000 per MA. Our calculation of training costs assumes that all the costs for training replacement MAs were incurred in 2017; because there is often a time lag between an MA leaving and a new employee being hired, as well as the 3-month duration of training, it is likely that some of the training occurred in 2018. This is balanced by the fact that we did not calculate costs of training MAs in 2017 who were hired to replace those who left in 2016.

Moreover, our work does not address the indirect costs of learning curves and decreased productivity for MAs, the other MAs and providers working with them, and patients in terms of satisfaction, provider productivity, patient safety, and organizational performance. From a systems perspective, we were not able to account for the potential benefits of employee turnover (i.e., bringing in fresh ideas and the lower salaries of less experienced staff), intangible losses (i.e., bringing knowledge of how our clinic works to competitors and employee morale), or the costs and benefits to MAs themselves or our patients. It is impossible to generalize our findings in a single practice in a region with high demand for MAs to other practices and other regions. Moreover, it is unclear to what degree, if any, the academic nature of our practice affected turnover rate or cost; measuring this would likely require a comparison with a similar, nonacademic practice.

As new models of care increasingly rely on MAs, it is important for health care systems to address the high turnover in this group of workers. Measuring this rate and its economic impact are the vital first steps that enable further research into the individual and system factors that promote and prevent MA turnover, a comparison of turnover rates between different practices and practice types, and evaluation of retention strategies. Increasing wages, adapting staffing models, and providing opportunities for career advancement have the potential to both increase overhead and decrease turnover cost. Clinics and health care systems must measure turnover rates and costs to make cost-effective decisions that maximize MA, clinician, and patient well-being.