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Research ArticleOriginal Research

Staffing Patterns of Primary Care Practices in the Comprehensive Primary Care Initiative

Deborah N. Peikes, Robert J. Reid, Timothy J. Day, Derekh D. F. Cornwell, Stacy B. Dale, Richard J. Baron, Randall S. Brown and Rachel J. Shapiro
The Annals of Family Medicine March 2014, 12 (2) 142-149; DOI: https://doi.org/10.1370/afm.1626
Deborah N. Peikes
1Mathematica Policy Research, Princeton, New Jersey
PhD, MPA
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  • For correspondence: dpeikes@mathematica-mpr.com
Robert J. Reid
2Group Health Research Institute, Seattle, Washington
MD, PhD
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Timothy J. Day
3Centers for Medicare and Medicaid Services, Baltimore, Maryland
MSPH
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Derekh D. F. Cornwell
1Mathematica Policy Research, Princeton, New Jersey
PhD
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Stacy B. Dale
1Mathematica Policy Research, Princeton, New Jersey
MPA
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Richard J. Baron
4American Board of Internal Medicine, Philadelphia, Pennsylvania
MD, MACP
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Randall S. Brown
1Mathematica Policy Research, Princeton, New Jersey
PhD
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Rachel J. Shapiro
1Mathematica Policy Research, Princeton, New Jersey
MPP
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Tables

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    Table 1

    CPC Initiative Practice Characteristics Compared With National Benchmarks

    Practice CharacteristicCPC Initiative Practices
    (n = 496)
    National Benchmark
    Primary care or multispecialty practice: multispecialty, %11.96.1
    Ownership, %
     Owned by hospital, hospital system, academic institution, or HMO43.810.5
     Owned by physicians54.489.5
     Owned by government or other organization1.8NR
    Patient mix: African American patients, %4.613.4
    Patients per FTE physician in practice, average No.1,475.5NR
    Distribution of number of patients per FTE physicians in practice, %
     <5006.0NR
     500–1,00022.6NR
     1,000–1,49936.7NR
     1,500–1,99916.5NR
     2,000–2,4999.1NR
     ≥2,5009.0NR
    Primary care physicians attesting as meaningful users of electronic health records, %67.817.8
    Practice location, %
     Located in metropolitan area84.7NR
     Located in nonmetropolitan area15.3NR
    • CPC = Comprehensive Primary Care; FTE = full-time equivalent; HMO = health maintenance organization; NR = not reported.

    • Source: For CPC initiative practices, data for the percentage of African American patients per practice are from the Medicare Enrollment Data base; data on the number of patients per FTE physician per practice are from the patient roster; the other data are from the CPC initiative practice application. Metropolitan and nonmetropolitan areas are based on the US Census urban/rural continuum code as reported in the 2009 Area Resource File. National benchmarks for electronic health record meaningful use estimates are based on meaningful-use attestation data provided by CMS and reported by Wright et al.40 All other national benchmarks come from a survey fielded between July 2007 and March 2009 for the National Study of Small and Medium-Sized Physician Practices, a nationally representative, random sample of 1,325 practices with fewer than 20 physicians drawn from the IMS Healthcare Organization Services database. The survey had an overall response rate of 63.2%. Results were restricted to practices that had at least 33% primary care physicians. Unlike the CPC initiative sample, a practice was not restricted to clinicians who were practicing in the same physical location.

    • View popup
    Table 2

    Percentage of CPC Initiative Practices With Different Staff Types, by Practice Size

    Staff Type≤2 FTE Physicians>2–4 FTE Physicians>4–7 FTE Physicians>7–13 FTE Physicians>13 FTE PhysiciansAll Practices
    Practice sample, No. (%)216 (43.5)148 (29.8)92 (18.5)31 (6.3)9 (1.8)496 (100.0)
    Practices with each staff type, %
     Administrative staffa96.3100.0100.0100.0100.098.4
     Medical assistants79.295.996.793.588.988.5
     NPs, PAs52.848.648.974.2100.053.0
     LPNs, LVNs40.342.656.567.788.946.6
     RNs29.229.143.577.488.935.9
     Care managers/coordinators17.623.031.548.433.324.0
     Pharmacists1.46.812.025.833.37.1
     Social workers0.94.18.722.622.25.0
     Community service coordinators4.23.44.39.711.14.4
     Health educators2.33.46.56.522.24.0
     Nutritionists1.94.15.46.533.34.0
    • CPC = Comprehensive Primary Care; LPN = licensed practical nurse; LVN = licensed vocational nurse; NP = nurse practitioner; PA = physician assistant; RN = registered nurse.

    • Source: The CPC initiative practice survey, fielded October through December 2012.

    • ↵a Administrative staff include those managing reception, medical records, appointments, finance, etc.

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    Table 3

    Percentage of CPC Initiative Practices With Staff Types, by PCMH Status

    Staff TypePCMH Practicesa
    (n = 204)
    Other Practices
    (n = 292)
    Physicians100.0100.0
    Administrative staffb98.598.3
    Medical assistants93.185.3
    NPs, PAs53.452.7
    LPNs, LVNs40.251.0
    RNs41.232.2
    Care managers/coordinator41.711.6
    Pharmacists9.35.5
    Social workers7.43.4
    Community service coordinators5.93.4
    Health educators2.94.8
    Nutritionists5.92.7
    • CPC = Comprehensive Primary Care; FTE = full-time equivalent; LPN = licensed practical nurse; LVN = licensed vocational nurse; NP = nurse practitioner; PA = physician assistant; PCMH = patient-centered medical home; RN = registered nurse.

    • Source: The CPC initiative practice survey, fielded October through December 2012.

    • ↵a Practices were classified as a PCMH if they reported they had received PCMH recognition, accreditation, or certification from 1 or more of the following: The Accreditation Association of Ambulatory Healthcare, The Joint Commission, the National Committee for Quality Assurance, the Utilization Review Accreditation Association, or a state- or insurance plan–based recognition program.

    • ↵b Administrative staff include those managing reception, medical records, appointments, finance, etc.

    • View popup
    Table 4

    Mean Number of FTE Staff per FTE Physician—Among CPC Initiative Practices With Staff Type—by Practice Size

    Staff Type≤2 FTE Physicians
    (n = 216)
    >2–4 FTE Physicians
    (n = 148)
    >4–7 FTE Physicians
    (n = 92)
    >7 FTE Physicians
    (n = 40)
    All Practices
    (n = 496)
    Administrative staffa2.421.761.701.982.05
    Medical assistants1.761.311.231.111.45
    NPs, PAs0.970.490.380.200.65
    LPNs, LVNs1.380.780.660.530.95
    RNs1.040.540.380.310.64
    Care managers/coordinators0.770.460.240.230.47
    Pharmacists0.750.420.150.290.32
    Social workers0.750.220.130.120.20
    Community service coordinators0.860.260.170.200.48
    Health educators1.000.370.190.100.42
    Nutritionists0.580.380.080.070.27
    • CPC = Comprehensive Primary Care; FTE = full-time equivalent; LPN = licensed practical nurse; LVN = licensed vocational nurse; NP = nurse practitioner; PA = physician assistant; RN = registered nurse.

    • Source: The CPC practice survey, fielded October through December 2012.

    • Note: Practice size is defined by the number of FTE physicians.

    • ↵a Administrative staff include those managing reception, medical records, appointments, finance, etc.

    • View popup
    Table 5

    Staffing Ratios, Overall, and by Practice Size and PCMH Status

    Staff TypePractice SizePCMH StatusAll Practices
    ≤2 FTE Physicians>2–4 FTE Physicians>4–7 FTE Physicians>7–13 FTE Physicians>13 FTE PhysiciansPCMH PracticesOther Practices
    Ratio of FTE nonphysician staff to FTE physician
    All nonphysician staffa5.323.923.734.233.354.404.574.50
     All nonadministrative staff2.992.162.042.211.522.502.482.49
     Administrative staff2.331.761.702.021.831.902.092.01
    FTE physicians
    Average number of FTE physicians1.43.45.59.427.74.33.43.7
    Median number of FTE physicians1.03.05.09.015.63.02.93.0
    • CPC = Comprehensive Primary Care; FTE = full-time equivalent; LPN = licensed practical nurse; LVN = licensed vocational nurse; NP = nurse practitioner; PA = physician assistant; PCMH = patient-centered medical home; RN = registered nurse.

    • Source: The CPC initiative practice survey, fielded October through December 2012.

    • Note: Practice size is defined by the number of FTE physicians. Practice status is based on whether a practice reported it had received PCMH recognition, accreditation, or certification from 1 or more of the following: The Accreditation Association of Ambulatory Healthcare, The Joint Commission, the National Committee for Quality Assurance, the Utilization Review Accreditation Association, or a state- or insurance plan–based recognition program.

    • ↵a Administrative staff include those managing reception, medical records, appointments, finance, etc. Nonadministrative staff include medical assistants, NPs/PAs, LPNs/ LVNs, RNs, care managers/coordinators, pharmacists, social workers, community service coordinators, health educators, and nutritionists.

Additional Files

  • Tables
  • The Article in Brief

    Staffing Patterns of Primary Care Practices in the Comprehensive Primary Care Initiative

    Deborah N. Peikes , and colleagues

    Background Team-based care is a cornerstone of new care models designed to deliver high-quality, comprehensive care efficiently, but little is known about appropriate staffing composition for team-based primary care. This report describes the size and staffing composition of 496 technologically-advanced practices in the Centers for Medicare and Medicaid Services Comprehensive Primary Care Initiative.

    What This Study Found There is a significant gap between where practices are and where policy makers expect them to be in order to implement new models of care. While most practices reported having administrative staff (98%) and medical assistants (89%), most did not have dedicated staff integral to providing team-based primary care ? staff who provide health education, care coordination, behavioral health care, nutrition counseling and medication adherence and reconciliation. Fifty-three percent reported having nurse practitioners or physicians assistants; 47% reported having licensed practical or vocational nurses; 36% reported having registered nurses; 24% reported having care managers and/or coordinators; and 7% or fewer reported having pharmacists, social workers, community service coordinators, health educators, or nutritionists.

    Implications

    • Without such staff and payment for their services, practices are unlikely to deliver comprehensive, coordinated and accessible care to patients at a sustainable cost.
    • The restricted staff composition found in this study may be a result of the current fee-for-service payment environment, which does not provide incentives for the delivery of comprehensive coordinated care.
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The Annals of Family Medicine: 12 (2)
The Annals of Family Medicine: 12 (2)
Vol. 12, Issue 2
March/April 2014
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Staffing Patterns of Primary Care Practices in the Comprehensive Primary Care Initiative
Deborah N. Peikes, Robert J. Reid, Timothy J. Day, Derekh D. F. Cornwell, Stacy B. Dale, Richard J. Baron, Randall S. Brown, Rachel J. Shapiro
The Annals of Family Medicine Mar 2014, 12 (2) 142-149; DOI: 10.1370/afm.1626

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Staffing Patterns of Primary Care Practices in the Comprehensive Primary Care Initiative
Deborah N. Peikes, Robert J. Reid, Timothy J. Day, Derekh D. F. Cornwell, Stacy B. Dale, Richard J. Baron, Randall S. Brown, Rachel J. Shapiro
The Annals of Family Medicine Mar 2014, 12 (2) 142-149; DOI: 10.1370/afm.1626
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