Primary Health Care in Community Health Centers and Comparison with Office-Based Practice

We examine the roles of nurse practitioners (NPs), physician assistants (PAs), and nurse midwives (CNMs) in community health centers (CHCs). We also compare primary care physicians in CHCs with office-based physicians. Estimates are from the National Ambulatory Medical Care Survey, a nationally representative annual survey of nonfederal, office-based patient care physicians and their visits. Analysis of primary care delivery in CHCs and office-based practices are based on 1,434 providers and their visits (n = 32,300). During 2006–2007, on average, physicians comprised 70% of CHC clinicians, with NPs (20%), PAs (9%), and CNMs (1%) making up the remainder. PAs, NPs, and CNMs provided care in almost a third of CHC primary care visits; 87% of visits to these CHC providers were independent of physicians. Types of patients seen by clinicians suggest a division of labor in caring for CHC patients. NPs and PAs were more likely than physicians to report providing health education services. There were no other differences among services examined. Office-based physicians were less likely to work alongside PAs/NPs/CNMs than CHC physicians. CHC staffing is contingent on a variety of providers. CHC staffing patterns may serve as models of primary care staffing for office practices as demand for primary care services nationwide increases.     

Use of midlevel practitioners to achieve labor cost savings in the primary care practice of an MCO

OBJECTIVE: To estimate the savings in labor costs per primary care visit that might be realized from increased use of physician assistants (PAs) and nurse practitioners (NPs) in the primary care practices of a managed care organization (MCO). STUDY SETTING/DATA SOURCES: Twenty-six capitated primary care practices of a group model MCO. Data on approximately two million visits provided by 206 practitioners were extracted from computerized visit records for 1997-2000. Computerized payroll ledgers were the source of annual labor costs per practice from 1997-2000. STUDY DESIGN: Likelihood of a visit attended by a PA/NP versus MD was modeled using logistic regression, with practice fixed effects, by department (adult medicine, pediatrics) and year. Parameter estimates and practice fixed effects from these regressions were used to predict the proportion of PA/NP visits per practice per year given a standard case mix. Least squares regressions, with practice fixed effects, were used to estimate the association of this standardized predicted proportion of PA/NP visits with average annual practitioner and total labor costs per visit, controlling for other practice characteristics. RESULTS: On average, PAs/NPs attended one in three adult medicine visits and one in five pediatric medicine visits. Likelihood of a PA/NP visit was significantly higher than average among patients presenting with minor acute illness (e.g., acute pharyngitis). In adult medicine, likelihood of a PA/NP visit was lower than average among older patients. Practitioner labor costs per visit and total labor costs per visit were lower (p<.01 and p=.08, respectively) among practices with greater use of PAs/NPs, standardized for case mix. CONCLUSIONS: Primary care practices that used more PAs/NPs in care delivery realized lower practitioner labor costs per visit than practices that used less. Future research should investigate the cost savings and cost-effectiveness potential of delivery designs that change staffing mix and division of labor among clinical disciplines.     

Effect of managed care and financing on practice constraints and career satisfaction in primary care

BACKGROUND: The shift away from third party insurers to risk-sharing arrangements affecting care management and clinicians could be the most fundamental change in the health care system. Analysis was undertaken to study how managed care, practice setting, and financial arrangements affect physicians' perceived impact on their practice. METHODS: Data were taken from the Community Tracking Study (CTS) physician survey, a national survey of active physicians in the United States fielded between August 1996 and August 1997. Survey instruments were completed by 7,146 primary care physicians in internal medicine (2,355), family practice (3,168), and pediatrics (1,623). The dependent variables are career satisfaction and perceived limitations and pressures on time spent with patients, clinical freedom, income, and continuity. To study the unique effect of financing and gatekeeping arrangements and practice setting, the dependent variables were regressed on gatekeeping, practice revenue, individual physician compensation, practice setting, specialty, age-group, sex, international medical graduate, board certification, and recent change in practice ownership. RESULTS: Total managed care revenue, or individual physician incentives, have no effect on career satisfaction and relatively limited effects on time pressure, income pressure, or patient continuity. In contrast, primary care gatekeeping has a highly significant adverse effect on the same outcome measures. After controlling for financial factors, demographic characteristics, and training differences, physicians in solo and 2-physician practices are significantly more likely to be dissatisfied with their medical career, more likely to report no clinical freedom, and more likely to feel income pressure than physicians in group practices, staff model HMOs, medical schools, or other settings. CONCLUSION: Physicians in solo and 2-physician practices were least satisfied with their careers and reported more constraints on their clinical freedom and income than physicians in other settings. Physicians in group practices or staff model HMOs are more likely to report time pressure than physicians in solo or 2-physician practices. Family practice falls between internal medicine (less satisfied, more practice constraints) and pediatrics (more satisfied, fewer practice constraints).     

Use of physician assistants and nurse practitioners in primary care, 1995-1999.

Federal policies and state legislation encourage the use of physician assistants (PAs) and nurse practitioners (NPs) in primary care, although the nature of their work has not been fully analyzed. In this paper we analyze primary care physician office encounter data from the 1995-1999 National Ambulatory Medical Care Surveys. About one-quarter of primary care office-based physicians used PAs and/or NPs for an average of 11 percent of visits. The mean age of patients seen by physicians was greater than that for PAs or NPs. NPs provided counseling/education during a higher proportion of visits than did PAs or physicians. Overall, this study suggests that PAs and NPs are providing primary care in a way that is similar to physician care.     

Examining attitudes of specialist physicians regarding physician assistant referrals

Referral of a patient from a primary care provider to a referral specialist physician for consultation is an important link in the continuum of patient care. Although the relationship between the physician assistant (PA) and supervising physician has been studied extensively, the effectiveness of the relationship between the primary care PA and the referral specialist physician is unclear. The purpose of this study was to examine the attitudes of the referral specialist physician toward direct referral of patients from primary care PAs. A random sample of 5,000 specialist physicians in five specialty areas across the United States were surveyed to determine their willingness to accept referrals from PAs, their attitudes about the appropriateness of PA referrals, and reasons for dissatisfaction, if any. Data analysis revealed that specialist physicians generally are willing to accept patient referrals from primary care PAs and that specialist physicians generally are satisfied with the appropriateness and timeliness of referrals from PAs. Whether or not the specialist physician employed (supervised) a PA in his or her own practice made a significant difference in level of satisfaction with PA referral. To determine the significance of these results, more research is needed to determine specialist physician satisfaction with referrals from primary care physicians compared with PAs.     

Primary care physician perceptions of the nurse practitioner in the 1990s.

OBJECTIVE: To evaluate factors associated with primary care physician attitudes toward nurse practitioners (NPs) providing primary care. DESIGN: A mailed survey of primary care physicians in Iowa. SETTING AND PARTICIPANTS: Half (N = 616) of the non-institutional-based, full-time, primary care physicians in Iowa in spring 1994. Although 360 (58.4%) responded, only physicians with complete data on all items in the model were used in these analyses (n = 259 [42.0%]). MAIN OUTCOME MEASURES: There were 2 principal dependent measures: physician attitudes toward NPs providing primary care (an 11-item instrument) and physician experience with NPs in this role. Bivariate relationships between physician demographic and practice characteristics were evaluated by chi 2 tests, as were both dependent variables. Ordinary least-squares regression was used to determine factors related to physician attitudes toward NPs. RESULTS: In bivariate analyses, physicians were significantly more likely to have had experience with an NP providing primary care if they were in pediatrics or obstetrics-gynecology (78.3% and 70.0%, respectively; P < .001), had been in practice for fewer than 20 years (P = .045), or were in practices with 5 or more physicians. The ordinary least-squares regression indicated that physicians with previous experience working with NPs providing primary care (P = .01), physicians practicing in urban areas with populations greater than 20,000 but far from a metropolitan area (P = .03), and general practice physicians (P = .04) had significantly more favorable attitudes toward NPs than did other primary care physicians. CONCLUSIONS: The association between previous experience with a primary care NP and a more positive attitude toward NPs has important implications for the training of primary care physicians, particularly in community-based, multidisciplinary settings.     

The contribution of nurse practitioners and physician assistants to generalist care in Washington State

OBJECTIVE: To quantify the total contribution to generalist care made by nurse practitioners (NPs) and physician assistants (PAs) in Washington State. DATA SOURCES: State professional licensure renewal survey data from 1998-1999. STUDY DESIGN: Cross-sectional. Data on medical specialty, place of practice, and outpatient visits performed were used to estimate productivity of generalist physicians, NPs, and PAs. Provider head counts were adjusted for missing specialty and productivity data and converted into family physician full-time equivalents (FTEs) to facilitate estimation of total contribution to generalist care made by each provider type. PRINCIPAL FINDINGS: Nurse practitioners and physician assistants make up 23.4 percent of the generalist provider population and provide 21.0 percent of the generalist outpatient visits in Washington State. The NP/PA contribution to generalist care is higher in rural areas (24.7 percent of total visits compared to 20.1 percent in urban areas). The PAs and NPs provide 50.3 percent of generalist visits provided by women in rural areas, 36.5 percent in urban areas. When productivity data were converted into family physician FTEs, the productivity adjustments were large. A total of 4,189 generalist physicians produced only 2,760 family physician FTEs (1 FTE = 105 outpatient visits per week). The NP and PA productivity adjustments were also quite large. CONCLUSIONS: Accurate estimates of available generalist care must take into account the contributions of NPs and PAs. Additionally, simple head counts of licensed providers are likely to result in substantial overestimates of available care. Actual productivity data or empirically derived adjustment factors must be used for accurate estimation of provider shortages.     

Quality of diabetes care in family medicine practices: influence of nurse-practitioners and physician's assistants

PURPOSE The aim of this study was to assess whether the quality of diabetes care differs among practices employing nurse-practitioners (NPs), physician’s assistants (PAs), or neither, and which practice attributes contribute to any differences in care.METHODS This cross-sectional study of 46 family medicine practices from New Jersey and Pennsylvania measured adherence to American Diabetes Association diabetes guidelines via chart audits of 846 patients with diabetes. Practice characteristics were identified by staff surveys. Hierarchical models determined differences between practices with and without NPs or PAs.RESULTS Compared with practices employing PAs, practices employing NPs were more likely to measure hemoglobin A_1c levels (66% vs 33%), lipid levels (80% vs 58%), and urinary microalbumin levels (32% vs 6%); to have treated for high lipid levels (77% vs 56%); and to have patients attain lipid targets (54% vs 37%) (P ≤ .005 for each). Practices with NPs were more likely than physician-only practices to assess hemoglobin A_1c levels (66% vs 49%) and lipid levels (80% vs 68%) (P≤.007 for each). These effects could not be attributed to use of diabetes registries, health risk assessments, nurses for counseling, or patient reminder systems. Practices with either PAs or NPs were perceived as busier (P=.03) and had larger total staff (P <.001) than physician-only practices.CONCLUSIONS Family practices employing NPs performed better than those with physicians only and those employing PAs, especially with regard to diabetes process measures. The reasons for these differences are not clear.     

Physician assistant practice in Minnesota; providing care as part of a physician-directed team

Physician assistants (PAs) practice medicine with physician supervision, which allows physicians to see more patients and concentrate their efforts on the needs of those with complex medical conditions. Physician assistants have been practicing in Minnesota since 1970. They work in a variety of settings and specialties, although most are in primary care practices. This article profiles the PA profession and describes the type of work PAs do, the training and credentialing required to become a PA, and the relationship between physicians and PAs.     

Autonomous ambulatory care by nurse practitioners and physician assistants in office-based settings

Data from the 1997 National Ambulatory Medical Care Survey were used to examine the autonomous provision of ambulatory medical care by nurse practitioners (NPs) and physician assistants (PAs) in physician-managed office-based settings. An estimated 6.81 million office visits involved autonomous care by NPs and PAs, for an overall rate of 2.55 visits per 100 persons. The visit rates were greatest for patients over 64 years of age, females, blacks, and patients from the Northeast. The visits encompassed a broad range of acute and chronic problems, with a greater proportion of non-illness care visits when compared with visits to physicians. While NPs and PAs provided diagnostic services and pharmacotherapy, there was more emphasis on therapeutic or preventive services in their practices than among physicians' practices. Predisposing, enabling, and need factors were differentially associated with visits to NPs and PAs. Utilization of NPs and PAs as autonomous providers in office-based settings appears limited. Public policy and educational initiatives can focus on predisposing, enabling, and need factors to increase access to autonomous practice of NPs and PAs in ambulatory care.     

Financial and organizational factors affecting the employment of nurse practitioners and physician assistants in medical group practices

This study examines the financial and organizational factors that are associated with the employment of nurse practitioners (NPs) and physician assistants (PAs) in medical group practices. The source of the data is a survey of 128 medical group practices in Minnesota. The findings suggest that the employment of NPs and PAs and their ratios to primary care physicians (PCPs) in practices that employ them are influenced by the organizational characteristics of the group practice but not by the degree of financial risk sharing for patient care. Although neither the number of years of experience in financial risk sharing nor more revenue from capitation payment contracts were related to employment of these midlevel practitioners (MLPs), large practices, those located in rural locations, not-for-profit practices, and those that scored low on cohesive cultural traits were more likely to employ MLPs. The data provide insights into the market for MLPs and the potential for these clinicians in the future health care system. As medical group practices become larger and have more organizational capacity, they can likely be expected to increase the employment of MLPs and integrate them into their organizations.     

Physician Assistants and Nurse Practitioners as a Usual Source of Care

ABSTRACT:  Purpose: To identify characteristics and outcomes of patients who use physician assistants and nurse practitioners (PA/NPs) as a usual source of care. Methods: Cross sectional analysis using the telephone and mail surveys of the Wisconsin Longitudinal Study (WLS), a prospective cohort study of Wisconsin high school graduates and selected siblings (n = 6,803). Findings: Individuals from metropolitan (OR = 0.40, 95% CI = 0.29-0.54) and micropolitan (OR = 0.65, 95% CI = 0.44-0.95) areas were less likely to utilize PA/NPs than participants from rural locations. Participants without insurance or with public insurance other than Medicare were more likely than those with private insurance to utilize PA/NPs (OR = 1.71, 95% CI = 1.02-2.86). Patients of PA/NPs were more likely to be women (OR = 1.77, 95% CI = 1.34-2.34), younger (OR = 0.95, 95% CI = 0.92-0.98) and have lower extroversion scores (OR = 0.81, 95% CI = 0.68-0.96). Participants utilizing PA/NPs reported lower perceived access (β=−0.22, 95% CI =−0.35-0.09) than those utilizing doctors. PA/NP utilization was associated with an increased likelihood of chiropractor visits (OR = 1.57, 95% CI = 1.15-2.15) and decreased likelihood of a complete health exams (OR = 0.74, 95% CI = 0.55-0.99) or mammograms (OR = 0.65, 95% CI = 0.45-0.93). There were no significant differences in self-rated health or difficulties/delays in receiving care. Conclusions: Populations served by PA/NPs and doctors differ demographically but not in complexity. Though perceived access to care was lower for patients of PA/NPs, there were few differences in utilization and no differences in difficulties/delays in care or outcomes. This suggests that PA/NPs are acting as primary care providers to underserved patients with a range of disease severity, findings which have important implications for policy, including clinician workforce and reimbursement issues.     

Growth of Physicians and Nurse Practitioners Practicing Full Time in Nursing Homes

ObjectivesThe objective was to describe the growth of physicians, nurse practitioners (NPs), and physician assistants (PAs) who practice full time in nursing homes, to assess resident and nursing home characteristics associated with receiving care from full-time providers, and describe variation among nursing homes in use of full-time providers.DesignRetrospective cohort study.Setting and ParticipantsA 20% national sample Medicare data on long-term care residents in 2008 to 2018 and the physicians, NPs, and PAs who submitted charges to Medicare for their care.MethodsWe measured the percentage of provider charges for services rendered in nursing homes, in addition to resident and facility characteristics.ResultsFull-time nursing home providers increased from 26.0% of all nursing home providers in 2008 to 44.6% in 2017. The largest increase was in NPs: from 1986 in 2008 to 4479 in 2017. Resident age, sex, Medicaid eligibility, and race/ethnicity had minimal association with the odds of having a full-time provider, whereas residents with an NP primary care provider were 23.0 times more likely (95% confidence interval = 21.6, 24.6) to have a full-time provider. Residents who received care from both a physician and an NP or PA increased from 33.6% in 2008 to 62.5% in 2018. There was large variation among facilities in the percentage of residents with full-time providers, from 5.72% of residents with full-time providers in the bottom quintile of facilities to 91.44% in the top quintile. Individual nursing homes accounted for 59% of the variation in whether a resident had a full-time provider.Conclusions and ImplicationsThe percentage of nursing home residents with full-time providers continues to grow, with very large variation among nursing homes.     

Physician assistants in occupational medicine: how do they compare to occupational physicians?

BACKGROUND: Physician assistants (PAs) have been present in occupational and environmental medicine (OEM) in the USA since 1971, yet remarkably little is known about their activity. METHODS: An administrative study of PA activities was undertaken and compared with the activities of physicians in the same occupational medicine setting. Patients were not triaged to either provider and all resources of care were recorded for the visit. An episode of care approach was used for the analysis. RESULTS: The characteristics of patients seen by each provider were similar in age, gender ratio and severity of injury. Physicians saw a mean of 2.9 patients/h and PAs 2.5, but PAs worked more hours and saw more patients per year than physicians. The average charge per patient visit and total charge for an episode of care were similar. Differences between PAs and physicians were seen in the areas of 'limited duty' duration given to patients and on average PAs prescribed 15 days and physicians 17 days. PAs referred a patient 19.7% of the time, while physicians referred 17.4%. Most of the referrals were to physical therapy. The salary of a physician, based on an hourly rate, was approximately twice as much as a PA. CONCLUSION: The use of PAs in OEM may represent a cost-effective advantage from an administrative standpoint. Clearly, more research is necessary in determining the role and utilization of PAs in OEM and how they may improve the delivery of physician services.     

Physician satisfaction in a managed care environment.

BACKGROUND. The professional literature suggests that changes toward the bureaucratization of medical practice have led to increasing job dissatisfaction, especially in primary care. To investigate this claim, we surveyed physicians in Dane County, Wisconsin, who practice in a bureaucratic setting. Dane County has experienced essentially a demise in independent practice, ie, most physicians practice in organizational settings where expenses and total patient income are pooled. About 85% of physicians have joined one of the six competing health maintenance organizations (HMOs). METHODS. In 1986 all 850 physicians in Dane County were surveyed to determine their perceptions of clinical freedom, satisfaction with income, status in their profession, autonomy, resources, and professional relations, and their overall satisfaction. RESULTS. We found that over 69% of primary care physicians were very satisfied or satisfied with their practices overall compared with 68% of physicians in all specialties. Differences between family practice and other primary care specialties were not statistically significant. Our regression analysis showed that only for satisfaction with income were responses from primary care physicians significantly different from those of physicians in surgical specialties. Perceptions of clinical autonomy and specific organizational settings were more important to predicting satisfaction. Also, age and sex contributed to differences in satisfaction with resources and status, respectively. CONCLUSIONS. We conclude that satisfaction can be fairly high for primary care physicians in bureaucratic settings similar to that of Dane County.     

Context of care or provider training: the impact on preventive screening practices

BACKGROUND: While MD adherence to U.S. Preventive Services Task Force guidelines has been found to be uneven, nurse practitioners (NPs) and their adherence to guidelines have not been closely examined. METHODS: A retrospective chart review of new patients (n = 1339) in an NP primary health care center, four MD primary health care centers, and one private NP practice. Screening and counseling were compared for NPs and MDs. RESULTS: When patient populations, resources, and administrative policies were similar in the NP and MD primary health care centers, NPs were more likely than MDs to perform primary prevention; however, MDs were more likely to document the delivery of secondary prevention screening. Private practice NPs' performance was more congruent with practice guidelines than either NP or MD primary health care center providers. Private practice NPs were more likely to perform screening, assessment, and counseling. CONCLUSIONS: When context, patient population, and productivity requirements were the same, NPs and MDs differed in their use of preventive measures, and not as expected. When NPs are not constrained by productivity requirements, and when their patient population has more resources and higher expectations, NPs perform better than their primary care center counterparts, particularly in secondary prevention and assessment and counseling.     

International medical graduates and the primary care workforce for rural underserved areas

The proportion of international medical graduates (IMGs) serving as primary care physicians in rural underserved areas (RUAs) has important policy implications. We analyzed the 2000 American Medical Association Masterfile and Area Resource File to calculate the percentage of primary care IMGs, relative to U.S. medical graduates (USMGs), working in RUAs. We found that 2.1 percent of both primary care USMGs and IMGs were in RUAs, where USMGs were more likely to be family physicians but less likely to be internists or pediatricians. IMGs appear to have been no more likely than USMGs were to practice primary care in RUAs, but the distribution by specialty differs.