NCHS Data Brief ■ No. 65 ■ July 2011

Community Health Centers: Providers, Patients, and Content of Care

Esther Hing, M.P.H.; and Roderick S. Hooker, Ph.D.

Key findings

Data from the National Ambulatory Medical Care Survey, 2006–2008

• In2006–2008,themajorityofcommunityhealthcenter(CHC)visitsweremadebyMedicaid-insuredoruninsuredpatients.

• Physiciansdeliveredcareat69%ofCHCvisits,nursepractitioners(NPs)at21%ofvisits,physicianassistants(PAs)at9%ofvisits,andcertifiednursemidwives(CNMs)at1%ofvisits.

• NPsandCNMssawahigherpercentageoffemalepatientsaged18–44thandidphysiciansorPAs.PhysiciansweremorelikelythanNPstoseepatientsaged45andover,bothmaleandfemale.PAsweremorelikelythanNPstoseemalesaged45andover.

• AhigherpercentageofNPandPAvisitsincludedhealtheducationandcounselingservicesthandidphysicianvisits.AlowerpercentageofCNMvisitsincludedprescribedmedicationsorimmunizations.

U.S. DEP

Formorethan40years,communityhealthcenters(CHCs)haveprovidedprimarycareandbehavioralandmentalhealthservicesinmedicallyunderservedcommunities,regardlessofapatient’sabilitytopay(1).In2001,thegovernmentlaunchedtheFederalHealthCenterGrowthInitiative,providingfundsover5yearstoincreaseby60%thenumberofpatientsservedin1,200communities.AsthenumberofCHCshasexpanded,demandforbothphysicianandnonphysicianpractitionerserviceshasincreased(2).ThisreportcomparespatientandencountercharacteristicsacrossthedifferenttypesofprovidersseenatCHCvisitsduringa3-yearperiod,2006–2008.

Keywords: physician assistants • nurse practitioners • nurse midwives

Who visits CHCs?

• During2006–2008,CHCsaveraged31.1millionvisitsannually(3,4).ThemajorityofvisitstoCHCs(55%)weremadebypatientswhowere

ARTMENT OF HEALTH AND HUMAN SERVICESCenters for Disease Control and Prevention

National Center for Health Statistics

NCHS Data Brief ■ No. 65 ■ July 2011

poororpubliclyinsured[41%MedicaidorStateChildren’sHealthInsuranceProgram(SCHIP)and14%uninsured]andbypatientsunderage45(64%)(Figure1).Aboutone-thirdofCHCvisits(32%)werebypatientsofblackorotherminorityracialgroups,andone-third(33%)werebyHispanicorLatinopatients.

• Comparablepercentagesofvisitstooffice-basedphysicianswiththesamevisitcharacteristicsweresignificantlylower:14%ofvisitstooffice-basedphysiciansweremadebyMedicaidandSCHIP(10%)oruninsured(4%)patients,45%bypatientsunderage45,16%bypatientsofblackorotherminorityracialgroups,and12%byHispanicorLatinopatients(datanotshown).

Who provides care at CHC visits, and who visits these providers?

• During2006–2008,69%ofCHCvisitsweretophysicians,21%toNPs,9%toPAs,and1%toCNMs(Table1).Only3%ofvisitsinvolvedbothaphysicianandanonphysicianpractitioner(datanotshown).

• NPs(36%)andCNMs(87%)sawahigherpercentageoffemalepatientsaged18–44thandidphysicians(25%)orPAs(22%).

• PhysiciansweremorelikelythanNPstoseepatientsaged45andover,bothmaleandfemale.PAsweremorelikelytoseemalesaged45andover(19%)thanwereNPs(8%).

• AlowerpercentageofpatientswithoneormorechronicconditionsvisitedNPs(39%)thanvisitedphysicians(52%)andPAs(58%),largelybecauseoftheyoungeragesofpatientsseenbyNPs.

• Physicians(72%)andPAs(72%)servedasthepatient’sprimarycareprovidermorefrequentlythanNPs(58%).

■  2  ■

Table 1. Percent distribution of community health center visits, by selected characteristics and provider type: United States, 2006–2008

Selected characteristic Physician Physician assistant Nurse practitioner Nurse midwifeTotal 100 100 100 100

Sex and age (years): Female, under 18 14 12 18 7

Female, 18–441–3 25 22 36 87

Female, 45 and over2 24 25 17 *

Male, under 18 14 11 13 *

Male, 18–44 9 12 8 –

Male, 45 and over2,3 15 19 8 –

One or more chronic conditions reported2,3 52 58 39 *18

Serves as patient’s primary care provider2,3 72 72 58 *42* Estimate does not meet standards of reliability or precision. – Quantity zero. 1Differences between nurse midwife and physician, and between nurse midwife and physician assistant, are statistically significant.   2Difference between nurse practitoner and physician is statistically significant. 3Differences between nurse practitioner and physician assistant are statistically significant.  

NOTES: Overall, 69% of visits were to physicians, 21% to nurse practitioners, 9% to physician assistants, and 1% to nurse midwives. Percentages may not add to 100 because of rounding. SOURCE: CDC/NCHS, National Ambulatory Medical Care Survey.

NCHS Data Brief ■ No. 65 ■ July 2011

Why do patients visit different types of providers?

• Asassessedbythehealthcareprovider,37%ofCHCvisitswereforanewproblem,29%wereforachronicproblem,31%wereforpreventivecare,and3%wereforotherreasons.

• PAstreatedahigherpercentageofnewproblems(45%)thandidphysicians(36%)(Figure2).

• Physicians(31%)andPAs(36%)hadahigherpercentageofvisitsforchronicconditionsthandidNPs(21%).

• ThevastmajorityofvisitstoCNMs(82%)wereforpreventivecare.Amuchlowerpercentageofvisitstophysicians(30%),PAs(17%),andNPs(38%)wereforpreventivecare.

■  3  ■

NCHS Data Brief ■ No. 65 ■ July 2011

Do different types of providers deliver different services?

• AhigherpercentageofvisitstoNPs(53%)andPAs(54%)includeddocumentationofhealtheducationorcounselingservicesinthemedicalrecord,comparedwithvisitstophysicians(42%)(Table2).

• Therewerenodifferencesamongphysicians,NPs,andPAsinthepercentagesofvisitsinwhichdrugsorimmunizationswereprescribedorcontinued,orlaboratoryorothertypesoftestswereorderedoradministered.

• ThepercentageofvisitstoCNMsinwhichlaboratoryandothertypesoftestswereorderedoradministered(59%)washigherthanthecomparablepercentageforphysicians(46%).

• ThepercentageofvisitstoCNMsinwhichdrugsorimmunizationswereprescribed(58%)waslowerthancomparablepercentagesamongphysicians(79%),NPs(72%),andPAs(82%).

■  4  ■

Table 2. Visits with selected services ordered or provided, by provider type: United States, 2006–2008

Selected service ordered or provided PhysicianPhysician assistant Nurse practitioner Nurse midwife

Percent

Drug or immunization mentioned1 79 82 72 58

Laboratory and other tests2,3 46 49 47 59

Health education service4,5 42 54 53 43

Any imaging 9 *11 8 *19

Nonmedication treatment6 10 15 10 *3

* Estimate does not meet standards of reliability or precision. 1Differences between nurse midwife and physician, and between nurse midwife and physician assistant, are statistically significant.   2Laboratory and other tests include scope procedures, biopsy, EKG/ECG, spirometry/pulmonary function test, and other services. 3Difference between nurse midwife and physician is statistically significant.   4Differences between nurse practitioner and physician, and between physician assistant and physician, are statistically significant.   5Health education services include education about asthma, diet and nutrition, exercise, growth and development, injury prevention, stress management, tobacco use and exposure, weight reduction, and other education. 6Nonmedication treatment includes complementary and alternative medicine, durable medical equipment, home health care, hospice care, physical therapy, radiation therapy, speech and occupational therapy, psychotherapy, other mental health counseling, excision of tissue, orthopedic care, wound care, other nonsurgical procedures, and other surgical procedures.

SOURCE: CDC/NCHS, National Ambulatory Medical Care Survey.

NCHS Data Brief ■ No. 65 ■ July 2011

Summary

Thisreporthaspresented2006–2008NationalAmbulatoryMedicalCareSurvey(NAMCS)estimatesofvisitstoCHCpractitioners.Duringthistimeperiod,asizeableportionofvisits(31%)weretoPAs,NPs,andCNMs.WithinCHCs,NPsandCNMsdisproportionatelyservedyoungwomencomparedwithpatientsservedbyphysicians,afindingconsistentwithothernationalstudies(5).ThevastmajorityofvisitstoCNMswereforpreventivecare.PAshadthehighestpercentageofvisitsfornewproblems.ThelargerpercentageofvisitstophysiciansandPAsbypatientsforachroniccondition,comparedwithvisitstoNPs,islargelyattributabletotheyoungerageofpatientsseenbyNPs.Therewerenosignificantdifferencesintypesofservicesprovidedbyphysicians,NPs,andPAs,withoneexception:PAsandNPsweremorelikelythanphysicianstoprovideordocumenthealtheducationorcounselingservicesatvisits.

CHCsservepredominantlylow-incomepatientswhoareuninsuredorwhorelyonpublicinsurance(6).ThesignificanceofCHCsassourcesofcarefortheuninsuredandunderinsuredhasgrownasaresultofrecentFederallyQualifiedHealthCenter(FQHC)expansionsandaworseningeconomy(6–10).In2008,visitstoCHCsaccountedfor14%ofallvisitstoprimarycaredeliverysitesbypatientswithMedicaidorSCHIPasaprimaryexpectedsourceofpayment,and12%ofvisitsbyuninsuredpatients(6).Primarycareisrecognizedasanimportantstrategyformaintainingpopulationhealthbecauseitisrelativelyinexpensive,canbemoreeasilydeliveredthanspecialtyandinpatientcare,andifproperlydistributedcouldbeeffectiveinpreventingdiseaseprogressiononalargescale(11).ThepresentreporthasdocumentedtherolesofnonphysicianpractitionersinCHCsacrossthenationfrom2006through2008.PAs,NPs,andCNMshavepartneredwithphysiciansandnursestoprovidecaretoawidespectrumofcommunities(12,13).TherolesofnonphysicianpractitionersinCHCsareexpectedtoincreaseasaresultofexpandedfundingforCHCinfrastructureincludedintheAmericanRecoveryandReinvestmentActof2009(14)andadditionalfundingforCHCexpansionandhealthinsurancecoveragefortheuninsuredincludedinthePatientProtectionandAffordableCareActof2010(15).MonitoringCHCutilizationandstaffingmayprovideinsightintothechangingnatureoftheU.S.healthcaresystem.

Definitions

CommunityHealthCenter(CHC):Anoutpatientclinicthatservesmedicallyunderservedpopulations(e.g.,migrantandseasonalagriculturalworkers,thehomeless,andpublichousingresidents)(1).CHCsrepresentedinNAMCSincludeFQHCclinicsthatreceiveSection330grantsunderthePublicHealthServiceAct,“look-alike”healthcentersthatmeetFQHCrequirements,andfederallyqualifiedurbanIndianHealthServiceclinics(1).

Healtheducationservices:Includeeducationaboutasthma,dietandnutrition,exercise,growthanddevelopment,injuryprevention,stressmanagement,tobaccouseandexposure,weightreduction,andrelatedtopics.

Majorreasonforvisit:Theprimaryreasonforthevisitasassessedbythehealthcareprovider.“Newproblem”visitsareforconditionswithonsetoflessthan3months.“Chronicproblem”visitsincluderoutineandflare-upvisits.“Preventivecare”includesvisitsforroutineprenatalandwell-babycare,screening,andinsuranceandgeneralexams.

■  5  ■

NCHS Data Brief ■ No. 65 ■ July 2011

Nonmedicationtreatment:Includescomplementaryandalternativemedicine,durablemedicalequipment,homehealthcare,hospicecare,physicaltherapy,radiationtherapy,speechandoccupationaltherapy,psychotherapy,othermentalhealthcounseling,excisionoftissue,orthopediccare,woundcare,othernonsurgicalprocedures,andothersurgicalprocedures.

Data sources and methods

AllestimatesarefromNAMCS—anannualnationallyrepresentativesurveyofvisitstononfederaloffice-basedphysiciansintheUnitedStates,conductedbytheCentersforDiseaseControlandPrevention’s(CDC)NationalCenterforHealthStatistics(NCHS).NAMCSusesamultistageprobabilitysampledesigninvolvinggeographicprimarysamplingunits(PSUs),physicianpracticeswithinPSUs,andpatientvisitswithinphysicianpractices.SampledphysicianswereselectedfromthemasterfilesoftheAmericanMedicalAssociationandtheAmericanOsteopathicAssociation.Startingin2006,NAMCSincludedanadditionalstratumof104CHCsinthesample.

The2006–2008NAMCSsamplesincluded312CHCswithinPSUs.WithinCHCs,asampleofuptothreeCHCproviders(physicians,PAs,NPs,orCNMs)scheduledtoseepatientsduringthesampleweekwasselected,andarandomsampleofvisitsduringanassignedweekwasselectedforeachCHCprovider.Amongin-scopeandeligibleCHCs,theoverallunweightedfour-stagesamplingresponseratewas85.5%(86.3%,weighted).ParticipatingCHCscompletedatotalof17,128patientrecordforms.

Weightsthattakeintoaccountallsamplestages,withadjustmentsfornonresponse,wereusedtoproduceaverageannualnationalestimatesofphysicianandnonphysicianclinicianofficevisits.DifferencesinvisitcharacteristicsfornonphysiciancliniciansandforphysicianswereanalyzedusingChi-squaretestsatthep=0.05level.Toaccountforthecomplexsampledesignduringvarianceestimation,allanalyseswereperformedusingtheSUDAANsoftwarepackage,version9.0(RTIInternational,ResearchTrianglePark,NC).

Theweightedpercentageofmissingdataobservedinthedatawasasfollows:patientageandsex(lessthan5%),race(24%),andethnicity(20%).Thesedatawereimputed(3),butthepotentialforbiasincreasesastheamountofmissingdataincreases.Therefore,theraceandethnicitydatashouldbeinterpretedwithcaution.AsnotedinFigure2,2%ofdataweremissingfor“majorreasonforvisit”andwereincludedwithpre-andpostsurgicalvisits.

About the authors

EstherHingiswiththeCentersforDiseaseControlandPrevention’sNationalCenterforHealthStatistics,DivisionofHealthCareStatistics.RoderickS.HookeriswithTheLewinGroup.

References

1. TaylorJ.Thefundamentalsofcommunityhealthcenters.NationalHealthPolicyForumbackgroundpaper.Washington,DC:TheGeorgeWashingtonUniversity.2004.Availablefrom:http://www.nhpf.org/library/background-papers/BP_CHC_08-31-04.pdf.

■  6  ■

NCHS Data Brief ■ No. 65 ■ July 2011

2. RosenblattRA,AndrillaCH,CurtinT,HartLG.Shortagesofmedicalpersonnelatcommunityhealthcenters:Implicationsforplannedexpansion.JAMA295(9):1042–9.2006.

3. NationalCenterforHealthStatistics.Communityhealthcenternonphysicianpractitionerdatafromthe2006–2008NationalAmbulatoryMedicalCareSurvey.Public-usedatafiledocumentation.Hyattsville,MD:NationalCenterforHealthStatistics.Forthcoming.

4. NationalCenterforHealthStatistics.NationalAmbulatoryMedicalCareSurvey,2006,2007,and2008.Public-usedatafiledocumentation.Hyattsville,MD:NationalCenterforHealthStatistics.Availablefrom:http://www.cdc.gov/nchs/ahcd/ahcd_questionnaires.htm.

5. DrussBG,MarcusSC,OlfsonM,TanielianT,PincusHA.TrendsincarebynonphysiciancliniciansintheUnitedStates.NEnglJMed348(2):130–7.2003.

6. HingE,UddinS.Visitstoprimarycaredeliverysites:UnitedStates,2008.NCHSdatabrief,no47.Hyattsville,MD:NationalCenterforHealthStatistics.2010.Availablefrom:http://www.cdc.gov/nchs/data/databriefs/db47.pdf.

7. O’MalleyAS,ForrestCB,PolitzerRM,WuluJT,ShiL.Healthcentertrends,1994–2001:WhatdotheyportendfortheFederalGrowthInitiative?HealthAff(Millwood)24(2):465–72.2005.

8. InglehartJK.Spreadingthesafetynet—Obstaclestotheexpansionofcommunityhealthcenters.NEnglJMed358(13):1321–3.2008.

9. LoSassoAT,ByckGR.Fundinggrowthdrivescommunityhealthcenterservices.HealthAff(Millwood)29(2):289–96.2010.

10. HurleyR,FellanL,LauerJ.Communityhealthcenterstacklerisingdemandsandexpectations.IssueBriefCentStudHealthSystChange(116):1–4.2007.

11. StarfieldB,ShiL,MacinkoJ.Contributionofprimarycaretohealthsystemsandhealth.MilbankQ83(3):457–502.2005.

12. HingE,HookerRS,AshmanJJ.Primaryhealthcareincommunityhealthcentersandcomparisonwithoffice-basedpractice.JCommunityHealth36(3):406–13.2011.

13. HookerRS,McCaigLF.Useofphysicianassistantsandnursepractitionersinprimarycare,1995–1999.HealthAff(Millwood)20(4):231–8.2001.

14. AmericanRecoveryandReinvestmentActof2009(ARRA):Summaryofmajorhealthcareprovisions[online].AmericanMedicalAssociation.2009.Availablefrom:http://www.ama-assn.org/ama/pub/advocacy/current-topics-advocacy/additional-advocacy-topics/american-recovery-and-investment-act.page.

15. Communityhealthcenters:Opportunitiesandchallengesofhealthreform.Issuepaper.KaiserCommissiononMedicaidandtheUninsured.2010.Availablefrom:http://www.kff.org/uninsured/upload/8098.pdf.

■  7  ■

NCHS Data Brief ■ No. 65 ■ July 2011

Suggested citation

HingE,HookerRS.Communityhealthcenters:Providers,patients,andcontentofcare.NCHSdatabrief,no65.Hyattsville,MD:NationalCenterforHealthStatistics.2011.

Copyright information

Allmaterialappearinginthisreportisinthepublicdomainandmaybereproducedorcopiedwithoutpermission;citationastosource,however,isappreciated.

National Center for Health Statistics

EdwardJ.Sondik,Ph.D.,Director JenniferH.Madans,Ph.D.,Associate Director for Science

Division of Health Care Statistics JaneE.Sisk,Ph.D., Director

U.S.DEPARTMENTOFHEALTH&HUMANSERVICES

CentersforDiseaseControlandPreventionNationalCenterforHealthStatistics3311ToledoRoadHyattsville,MD20782

OFFICIALBUSINESSPENALTYFORPRIVATEUSE,$300

Toreceivethispublicationregularly,contacttheNationalCenterforHealthStatisticsbycalling1–800–232–4636E-mail:cdcinfo@cdc.govInternet:http://www.cdc.gov/nchs

FIRST CLASS MAIL POSTAGE & FEES PAID

CDC/NCHS PERMIT NO. G-284

ISSN 1941–4927 (Print ed.) ISSN 1941–4935 (Online ed.) CS224473DHHSPublicationNo.(PHS)2011–1209