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

Esther Hing; Roderick S. Hooker; Jill J. Ashman

J Community Health. 2011;36(3):406-413.

Abstract and Introduction

Abstract

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.

Introduction

In the US, non-physician clinicians (physician assistants (PAs), nurse practitioners (NPs) and nurse midwives (CNMs)) are underutilized in primary care practices. The reasons for this vary; from higher pay in subspecialty areas to lifestyle preferences.^[1] Although PAs were introduced to bolster the primary care workforce, options have grown in both surgical and medical specialties.^[2] In addition, primary care practices often cannot afford to provide non-physician clinician services since the current visit-based payment system provides disincentives to their use,^[3,4] while state regulations regarding both the scope of practice and prescribing authority for NPs hinder utilizing NPs to their full potential.^[5] Finally, physician training and culture has not emphasized working as part of a team; most physicians are trained to work autonomously.^[6,7]

Community health centers (CHCs) are an exception in primary care. For 40 years, CHCs have delivered primary care to the uninsured, the homeless, migrant workers, and other medically underserved populations.^[8] To receive Section 330 grant funds through the Public Health Service Act, CHCs, (also known as federally qualified health centers [FQHCs]), must provide comprehensive primary health care services as well as ancillary services that facilitate access to health care including case-management, translation and transportation services. This wide array of CHC services has fostered a team-based approach to managing health care among physicians, non-physician clinicians and other CHC staff.^[9,10] Examination of CHC utilization patterns may help delineate the roles served by these clinicians.

We examined care provided by primary care providers [physicians, nurse practitioners (NPs) and physician assistants (PAs)] among federally funded and look-alike CHCs. We also compared physician and visit characteristics of primary care physicians in CHCs and office-based practices. In this paper, primary care physicians include those in general and family practice, internal medicine, pediatrics, and obstetrics/gynecology. Patterns of care were examined using data from 2006 and 2007 National Ambulatory Medical Care Survey (NAMCS), a nationally representative survey of visits to non-federal office-based physicians. Reliable CHC clinician and visit estimates are made possible by the inclusion of a separate stratum of CHCs in NAMCS beginning in 2006.

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J Community Health. 2011;36(3):406-413. © 2011 Springer
Springer Science+Business Media

Cite this: Primary Health Care in Community Health Centers and Comparison with Office-based Practice - Medscape - Jun 01, 2011.

Table 1. Number and percentage of providers and visits in community health centers, by type of provider, 2006–2007
Type of provider	Number	Percent
	Number of providers^b
All providers	11,800	100.0
Physician	8,200	69.3
Non-physician clinician	3,600	30.7
NP	2,200	18.3
PA	1,100	9.5
CNM	400^a	3.0^a
	Number of visits in thousands^b
All providers	28,338	100.0
Physician	19,889	70.2
Non-physician clinician^c	8,449	29.8
NP	5,927	20.9
PA	2,153	7.6
CNM	400^a	1.3^a

SOURCE National Ambulatory Medical Care Survey, 2006–2007
Notes: PA is physician assistant, NP is nurse practitioner, CNM is nurse midwife
^aThis figure does not meet National Center for Health Statistics (NCHS) standard of reliability or precision (that is, has a coefficient of variation greater than 30 percent)
^bAveraged over 2006–2007
^cAt an estimated 1,037,00 visits, both a physician and non-physician clinician was seen at the patient visit (12.3 percent of all non-physician clinician visits)

Table 2. Patient characteristics of community health center visits according to type of provider, 2006–2007
Patient characteristic	Physician	NP	P-value**	PA	P-value**
Age	100.0	100.0		100.0
Under 18 years	28.5	22.5	.27	29.8	.89
18–39 years	27.8	40.2	.04	25.4	.57
40–64 years	31.8	31.8	–	33.0	.84
65 years and over	11.9	5.5	<.01	11.8	.98
Sex
Female	62.0	72.7	<.01	55.9	.10
Male	38.0	27.3	<.01	44.1	.10
Race/ethnicity
Non-Hispanic White	39.4	48.3	.35	56.5	.14
Non-Hispanic Black	26.1	18.8	.30	18.4	.45
Hispanic	23.1	27.6	.64	16.5	.41
Other	11.4	5.4	.21	8.6	.72
Primary expected payment source
Private insurance	13.3	13.6	.92	24.6	.07
Medicare	11.5	5.9	<.01	6.8	.05
Medicaid or SCHIP	45.3	37.2	.12	35.5	.21
Uninsured	15.9	16.5	.88	11.5^a
Other	5.2	16.6	.07	5.3^a
Unknown	8.8	10.1	.71	16.3^a
Has one or more chronic condition	50.7	42.6	.12	48.7	.75
Selected chronic conditions
Hypertension	25.1	19.4	.08	22.7	.67
Hyperlipidemia	13.8	11.9	.43	13.6	.95
Diabetes	12.8	11.7	.58	11.0	.53
Depression	10.6	12.5	.51	10.8	.94
Arthritis	9.8	5.9	.02	6.8	.09
Asthma	7.1	6.6	.72	6.8	.75
Obesity	8.7	10.0	.51	6.8	.16
COPD	3.5	3.5	–	6.5^a

SOURCE National Ambulatory Medical Care Survey, 2006–2007
Notes: PA is physician assistant, NP is nurse practitioner. Medicaid includes patients dually eligible for Medicare and Medicaid, SCHIP is State Children's Health Insurance Program, COPD is chronic obstructive pulmonary disease
– Quantity zero
^aThis figure does not meet National Center for Health Statistics (NCHS) standard of reliability or precision (that is, has a coefficient of variation greater than 30 percent)
** P-value associated with a t test of the difference in the percentage of visits relative to physician visits

Table 3. Visit characteristics of community health center visits according to type of provider, 2006–2007
Visit characteristics	Physician	NP	P-value**	PA	P-value**
	Percent of visits
All visits	100.0	100.0		100.0
Established patient	89.3	89.4	.96	87.1	.46
Major reason for visit
Preventive care	32.1	38.2	.29	21.8	.11
Chronic condition (routine or flare-up)	30.9	24.5	.11	28.9	.70
Acute Condition	33.9	34.0	.98	48.0	.01
Pre-/post-surgery/unknown	3.0	3.3^a		1.4^a
Selected services ordered or provided
Diagnostic or screening service	97.9	97.5	.61	98.3	.64
Health education	44.8	57.4	.01	63.6	.01
Non-medication treatment	9.2	11.3	.54	11.1	.36
Medication prescribed	76.6	71.8	.39	75.6	.86
Disposition of the visit
No follow-up	4.8	5.0	.90	4.9	.95
Specialty referral	11.0	10.4	.73	10.7	.90
Return at specified time	72.3	63.0	.10	58.5	.01
Return if needed	21.7	30.6	.13	35.5	<.01

SOURCE National Ambulatory Medical Care Survey, 2006–2007
Notes: PA is physician assistant, NP is nurse practitioner
^aThis figure does not meet National Center for Health Statistics (NCHS) standard of reliability or precision (that is, has a coefficient of variation greater than 30 percent)
** P-value associated with a t-test of the difference in the percentage of visits relative to physician visits

Table 4. Comparison of community health center and office-based primary care physicians, 2006–2007
Physician or practice characteristic	Community health center	Physician office	P-value for difference
	Percent of physicians
	100.0	100.0
Percent reporting one or more non-physician clinician in the practice	87.7	43.9	<.01
	Average
Number of non-physician clinicians at location where most patients are seen	3.4	2.5	<.01
Percent of physicians
Percent accepting new patients	97.7	93.3	.03
Percent accepting new patients by payment source
No charge or charity	81.3	38.8	<.01
Worker's compensation	75.6	46.5	<.01
Capitated private insurance	75.9	59.4	<.01
Medicaid	97.3	66.1	<.01
Medicare	96.4	75.5	<.01
Noncapitated private insurance	91.6	84.9	.04
Self pay	96.5	89.2	<.01
Physician sees patients during evening or weekend hours	50.0	38.2	.04
Practice sets aside time for same day appointments (2007 only)
Yes	77.4	69.6	.36
No	19.5	24.4	.56
Unknown	3.2	6.1	.15
	Average
Percent of daily visits that are same day appointments (2007 only)	32.2	24.3	.25
	Percent of physicians
Referral difficulties by payment source (2006 only)
Uninsured	66.4	35.5	<.01
Medicaid	56.0	36.1	.03
Medicare	15.4	11.0	.33
Private insurance	11.5^a	13.7	.70

SOURCE National Ambulatory Medical Care Survey, 2006–2007
^aThis figure does not meet National Center for Health Statistics (NCHS) standard of reliability or precision (that is, has a coefficient of variation greater than 30 percent)

Table 5. Characteristics of visits to primary care physicians at community health centers and physician offices, 2006-07
Visit characteristics	Community health center	Physician offices	P-value for difference
	Percent of visits
All visits	100.0	100.0
Established patient	89.3	90.6	.21
Major reason for visit
Preventive care	32.1	27.7	.08
Chronic condition (routine or flare-up)	30.9	26.7	.14
Acute Condition	33.9	41.7	<.01
Pre-/post-surgery/unknown	3.0	3.9	.21
Selected services ordered or provided
Diagnostic or screening service	97.9	96.0	<.01
Health education	44.8	39.7	.19
Non-medication treatment	9.2	10.2	.48
Medication prescribed	76.6	76.9	.86
Disposition of the visit
No follow-up	4.8	7.8	.01
Specialty referral	11.0	8.4	<.01
Return at specified time	72.3	58.1	<.01
Return if needed	21.7	33.1	<.01
	Average
Duration of visit in minutes	18.7	18.8	.91

SOURCE National Ambulatory Medical Care Survey, 2006–2007

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