Primary Care Practice Characteristics Associated With Medical Assistant Staffing Ratios

INTRODUCTION

Medical assistants (MAs) are among the fastest growing occupations within the US primary care workforce,¹ but little is known about organizational factors associated with MA support levels for primary care clinicians (PCCs). Increased accountability for quality of care has led many practices to expand roles for primary care MAs, including health coaching for adults with chronic conditions.^2-4 Interprofessional care team approaches rely on robust support from MAs; for example, the teamlet model of primary care recommends 2 MAs per PCC.⁵

We examine primary care characteristics associated with MA staffing ratios. Past evidence indicates that health care system ownership of primary care practices may impede patient-centered innovation, such as MA role expansion, because they require resources that may not be sufficiently aligned with existing health care system goals or incentives.⁶

METHODS

RESULTS

Most adult primary care practices (56.6%) had ratios of 1 MA per PCC, while only 11.4% had ratios of 2 or more MAs per PCCs; 27.6% had ratios of less than 1:1, and 4.3% of practices did not employ MAs (Table 1). In adjusted analyses, compared with system-owned practices, independent (odds ratio [OR] = 1.76, P <0.05) and medical group–owned (OR = 2.09, P <0.05) practices had significantly greater odds of having ratios of 2 or more MAs per PCC (Table 2). Practices with organizational cultures oriented to innovation (OR = 1.35, P <0.05) had greater odds of having ratios of 2 or more MAs per PCC.

DISCUSSION

Approximately 1 in 10 adult primary care practices have ratios of 2 or more MAs per PCC. Independent practices, medical group–owned practices, and FQHC practices were more likely to have ratios of 2 or more MAs per PCC ratios than practices owned by health care systems. Practice ownership may influence managerial control and physician autonomy to determine staffing levels that enable high-quality, patient-centered primary care.¹² Practices with cultures oriented to innovation were also more likely to have staffing ratios of 2 or more MAs per PCC, possibly because they were better able to retain MA staff during the COVID-19 pandemic federal emergency period.¹³

System-owned practices may opt to hire other staff, including nurses and other non-physician clinicians, instead of staffing 2 MAs per PCC.¹⁴ The number of advanced practice clinicians and the extent of non-physician clinicians’ involvement in complex care management processes, however, were not significantly associated with MA per PCC staffing ratios. These findings challenge the perception that MAs are substitutes for other care team members like nurses and behavioral health specialists.

Study limitations include a modest response rate, although comparable to large-scale organizational surveys conducted during the pandemic. Clinical and non-clinical efforts were not differentiated, and staffing records were not used to confirm the levels reported. Additional measures of practice culture and burnout could have enriched these analyses and should be examined in future research. Staffing ratios and cultural assessments were both self-reported, so common method bias is another potential limitation.

The National Academy of Sciences, Engineering, and Medicine’s Committee on Implementing High-Quality Primary Care recommended greater investment in primary care as a key step toward improving population health.¹⁵ Most primary care practices do not have adequate MA support. Ensuring that PCCs have sufficient MA support is a concrete step that payers and organizations can take to support primary care practices.