Finding Money in the Margins: A Mindset for Sustainable Mission Impact

Written By David Hughes

Across the country, community health centers are facing a difficult reality. Demand for care continues to grow, workforce shortages persist, and financial margins are tightening. Many health centers are doing extraordinary work—and still losing money.

The question FQHC Forward asks is simple but powerful:

What if the resources we need are already inside our organizations—hidden in the margins?

“Finding Money in the Margins” is not about chasing volume at the expense of mission. It is about reclaiming lost capacity, reducing friction in daily operations, and deliberately investing in systems that help providers do what they came to do: care for patients—well, efficiently, and sustainably.

The Balance We Must Strike

Every health center is constantly balancing three equally important priorities:

  • Provider of Choice – supporting clinicians, reducing burnout, and enabling them to practice at the top of their license

  • Employer of Choice – building stable, engaged teams with clear expectations and fair accountability

  • Sustainability – generating enough margin to reinvest in access, staff, technology, and long-term mission

When any one of these is neglected, the system strains. When they are aligned, the organization becomes resilient.

Finding money in the margins is about alignment, not austerity.

The Core Insight: Time Is the Scarce Resource

Health centers often describe their biggest challenges as “lack of money” or “lack of providers.” Those are symptoms—not root causes.

The real constraint is time.

Unfilled appointment slots, inefficient workflows, underutilized panels, EHR friction, denied claims, and mismatched staffing models all quietly drain time—and time is revenue, access, and morale.

Margins are lost not in big decisions, but in thousands of small inefficiencies that compound every day.

A Deliberate Investment: Practice Transformation

At Elica Health Centers, these challenges led to a fundamental shift in thinking:

Instead of asking, “How do we do more with less?”
The organization asked, “What happens if we dedicate resources—on purpose—to process improvement?”

The result was a fully resourced Practice Transformation (PTX) function—a cross-functional team focused on:

  • Provider productivity and access to care

  • Clinical support optimization

  • Scheduling and panel management

  • EHR efficiency and workflow design

  • Revenue cycle performance and reimbursement integrity

This work was not treated as a side project or a “problem of the month.” It became core infrastructure.

Two Levers That Matter Most

Nearly every initiative in the presentation ties back to two fundamental drivers of sustainability:

1. Provider Productivity (Access to Care)

  • Balanced patient panels

  • Open access scheduling that actually gets used

  • Eliminating unfilled appointment slots

  • Ensuring clinical support staff work at the top of their scope

  • Reducing documentation burden and after-hours work

Productivity here is not about rushing visits—it’s about removing obstacles that prevent providers from seeing patients they are already willing and able to serve.

2. Reimbursement Optimization (Revenue Integrity)

  • Maximizing the blended encounter rate through payer mix awareness

  • Protecting PPS reimbursement through accurate visits, cost reporting, and compliance

  • Reducing denials through operational ownership of revenue cycle management

  • Recognizing that billing and coding alone do not fix broken workflows

Together, these two levers generate capacity and margin without compromising mission.

Why This Approach Works

Practice Transformation succeeds because it:

  • Treats inefficiency as solvable, not inevitable

  • Uses data to guide coaching—not punishment

  • Supports providers instead of blaming them

  • Invests in systems instead of heroic effort

  • Aligns operations, finance, clinical leadership, and IT

Most importantly, it recognizes that margin is not the enemy of mission. Margin is what allows mission to survive.

A Call to Rethink What’s Possible

Every health center has money hidden in its margins. Not as cash sitting unused—but as unrealized capacity, lost encounters, denied claims, and burned-out staff.

The challenge is not whether opportunities exist.
The challenge is whether leadership is willing to dedicate resources to finding them.

Finding Money in the Margins is a mindset shift:
From scarcity to stewardship.
From reaction to design.
From survival to sustainability.

That is the work FQHC Forward exists to support.

David Hughes