Study: Care by NPs, PAs Equal Doctors in Community Health

Today, millions of Americans rely on community health centers for their healthcare. These nonprofit organizations are generally located in urban, medically underserved areas, and have grown with the Medicaid expansion under the Affordable Care Act (ACA). According to data collected by the Health Resources and Services Administration (HRSA), 805,064 patients were treated by community health centers in 2010, the same year the ACA was passed. In 2015, the HRSA reported more than 24 million patients received treatment from community health centers. 

This increased usage of community health centers, combined with a nationwide physician shortage, has led to increased demand for NPs and PAs in these types of healthcare settings. This has sparked debate as to whether NPs and PAs are providing patients with the same quality care of a physician.

Physicians Practice recently spoke with Ellen Kurtzman, Ph.D., associate professor in the School of Nursing at George Washington University in Washington, D.C., who along with Burt Barnow, Ph.D., professor in GW's Trachtenberg School of Public Policy & Public Administration, conducted a study comparing the quality of care in community health centers administered by NPs, PAs, and physicians, about the ongoing debate.

What did your study find regarding care administered by NPs, PAs, and physicians?

The study is a comparison between the practice of NPs, PAs, and primary-care physicians in a particular setting of care….community health centers. In comparing these practitioners, I looked specifically at nine outcomes, three quality of care indicators [smoking cessation counseling, depression treatment, ordering/prescribing of statins for hyperlipidemia], four measures of service utilization [physical exams, total number of health education/counseling services, imaging services, total number of medications], and two measures of referral pattern [return visits, physician referrals].

We were able to take secondary data compiled by the federal government and compare these practitioners over a five -year period, from 2006 to 2010. The general overall finding is that the care and practice of these practitioners is very similar across the nine outcomes that we studied. This is not the first study on this topic, but it is the first study [on this topic], in this setting.

Why did you choose those indicators?       

We borrowed the indicators, as we didn't want to develop or identify measures of quality in isolation. We wanted to avoid people getting wrapped up in the outcomes we picked. The indicators were borrowed from other studies that used the same data set and modeled quality for other purposes. There are nearly a dozen studies where researchers use these same data and modeled the same outcomes for different reasons. We picked the indicators that were relevant and prevalent to the community health center population.

Why did you choose to study community health centers?

There has been fairly rapid growth [in community health centers], over the last 10 years or so. In 2007, there were about 1000 health centers [nationwide], in 2015 there were about 1400 health centers, and the number of patients served rose to 24 million. The estimates are that by 2019, these providers will be serving 40 million people nationwide. [Community health centers] are still a relatively small provider of care, but the growth is relatively impressive. The vulnerable population they serve is a really important population to the nation, in terms of a barometer for how we're doing in our providing care to the safety net. These are providers who have always engaged and employed people of all different backgrounds. They have always hired and employed PAs, NPs, and physicians.

Over the time period of the study, [community health centers] were shifting towards using more NPs and PAs. The growth of community health centers combined with their shift from predominantly physician-delivered care to care provided by a mix of practitioners, raises a policy question. Does [this discrepancy] matter? The fact is these providers are growing rapidly, caring for more people, and using a greater proportion of NPs and PAs. Should we as a country be concerned about that? Or should we accelerate the use of non-physician clinicians in this setting?

What are your thoughts on critics of PAs and NPs amid the rise in physician burnout?      

This study contributes to the body of literature that should reassure the public that care delivered by NPs and PAs is largely equivalent [to that of physicians]. It doesn't replicate other studies but extends their findings to an additional setting. Given our findings, what I would say to someone I wanted the best care for is that in [the community health center] setting, the care delivered is largely equivalent. To the admins and people who make hiring decisions, I would say they should feel reassured that hiring these practitioners in even greater numbers potentially, is going to maintain the quality of care and provide better access. A lot of these community health centers are in underserved areas and it's enormously difficult to recruit physicians. I would say the same thing to policy makers, there is a lot of debate about whether or not NPs should have more independence or whether they should be overseen by physicians and what that relationship looks like.

[NPs and PAs] are practitioners that are lower cost, optimize access for people, and by all accounts, provide equivalent care. That is a high-value proposition. That is an investment that the government and providers should be making. My take home message is that this is an area where the government and other payers could produce better value from the system.