Hostname: page-component-8448b6f56d-dnltx Total loading time: 0 Render date: 2024-04-18T23:45:40.618Z Has data issue: false hasContentIssue false
  • English
  • Français

Influence of provider mix and regulation on primary care services supplied to US patients

Published online by Cambridge University Press:  07 October 2015

Michael R. Richards  and
Daniel Polsky
Michael R. Richards*
Affiliation:
Assistant Professor, Department of Health Policy, Vanderbilt University, Nashville, TN, USA
Daniel Polsky
Affiliation:
Professor of Health Care Management, Executive Director, Leonard Davis Institute of Health Economics, Wharton School, University of Pennsylvania, PA, USA Professor of Medicine, Perelman School of Medicine, University of Pennsylvania, PA, USA
*
*Correspondence to: Assistant Professor Michael R. Richards, Department of Health Policy, Vanderbilt University, 2525 West End Ave, Suite 1206, Nashville, TN 37203, USA. Email: michael.r.richards@vanderbilt.edu
Get access Rights & Permissions [Opens in a new window]

Abstract

Access to medical care and how it differs for various patients remain key policy issues. While existing work has examined clinic structure’s influence on productivity, less research has explored the link between provider mix and access for different patient types – which also correspond to different service prices. We exploit experimental data from a large field study spanning 10 US states where trained audit callers were randomly assigned an insurance status and then contacted primary care physician practices seeking new patient appointments. We find clinics with more non-physician clinicians are associated with better access for Medicaid patients and lower prices for office visits; however, these relationships are only found in states granting full practice autonomy to these providers. Substituting more non-physician labor in primary care settings may facilitate greater appointment availability for Medicaid patients, but this likely rests on a favorable policy environment. Relaxing regulations for non-physicians may be an important initiative as US health reforms continue and also relevant to other countries coping with greater demands for medical care and related financial strain.

Type
Articles
Information
Health Economics, Policy and Law , Volume 11 , Issue 2 , April 2016 , pp. 193 - 213
Copyright
© Cambridge University Press 2015 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Allison, P. D. (1999), ‘Comparing logit and probit coefficients across groups’, Sociological Methods & Research, 28(2): 186–208.CrossRefGoogle Scholar
Baker, L. C. and Royalty, A. B. (2000), ‘Medicaid policy, physician behavior, and health care for the low-income population’, Journal of Human Resources, 35(3): 480–502.Google Scholar
Boardman, A. E., Dowd, B., Eisenberg, J. M. and Williams, S. V. (1983), ‘A model of physicians’ practice attributes determination’, Journal of Health Economics, 2: 259–268.CrossRefGoogle Scholar
Bodenheimer, T. and Pham, H. H. (2010), ‘Primary care: current problems and proposed solutions’, Health Affairs, 29(5): 799–805.Google Scholar
Bodenheimer, T., Berenson, R. A. and Rudolf, P. (2007), ‘The primary care – specialty income gap: why it matters’, Annals of Internal Medicine, 146: 301–306.CrossRefGoogle ScholarPubMed
Bodenheimer, T., Chen, E. and Bennett, H. D. (2009), ‘Confronting the growing burden of chronic disease: can the US health care workforce do the job?’, Health Affairs, 28(1): 64–74.Google Scholar
Brown, D. A. (1988), ‘Do physicians underutilize aides?’, Journal of Human Resources, 23(3): 342–355.Google Scholar
Buchmueller, T. C., Orzol, S. and Shore-Sheppard, L. D. (2013), ‘The Effect of Medicaid Payment Rates on Access to Dental Care Among Children’, NBER Working Paper Series (w19218): 1–50.Google Scholar
Buchmueller, T. C., Miller, S. and Vujicic, M. (2014), ‘How Do Providers Respond to Public Health Insurance Expansions? Evidence from Adult Medicaid Dental Benefits’, NBER Working Paper Series (No. 20053): 1–58.Google Scholar
Cassidy, A. (2013), ‘Health Policy Brief: Nurse Practitioners and Primary Care’, Health Affairs, RWJ Foundation.Google Scholar
Cooper, R. A. (2001), ‘Health care workforce for the twenty-first century: the impact of nonphysician clinicians’, Annual Review of Medicine, 52: 51–61.Google Scholar
Cooper, R. A. and Aiken, L. H. (2001), ‘Human imputs: the health care workforce and medical markets’, Journal of Health Politics, Policy and Law, 26(5): 925–938.Google Scholar
Cromwell, J. and Mitchell, J. B. (1984), ‘An economic model of large Medicaid practices’, Health Services Research, 19(2): 197–218.Google Scholar
Cunningham, J. and Cunningham, P. J. (2005), ‘The effects of Medicaid reimbursement on the access to care of Medicaid enrollees: a community perspective’, Medical Care Research and Review, 62(6): 676–696.Google Scholar
Decker, S. L. (2007), ‘Medicaid physician fees and the quality of medical care of Medicaid patients in the USA’, Review of Economics of the Household, 5: 95–112.CrossRefGoogle Scholar
Decker, S. L. (2009), ‘Changes in Medicaid physician fees and patterns of ambulatory care’, Inquiry, 46: 291–304.Google Scholar
Dobson, G., Pinker, E. and Van Horn, L. (2009), ‘Division of labor in medical office practices’, Manufacturing & Service Operations Management, 11(3): 525–537.Google Scholar
Fairman, J. A., Rowe, J. W., Hassmiller, S. and Shalala, D. E. (2011), ‘Broadening the scope of nursing practice’, New England Journal of Medicine, 364: 193–196.CrossRefGoogle ScholarPubMed
Glied, S., Prabhu, A. G. and Edelman, N. (2009), ‘The cost of primary care doctors’, Forum for Health Economics & Policy, 12(1): 1–26.CrossRefGoogle Scholar
Hofer, A. N., Abraham, J. M. and Moscovice, I. (2011), ‘Expansion of coverage under the patient protection and affordable care act and primary care utilization’, Milbank Quarterly, 89(1): 69–89.Google Scholar
Hogg, W., Rowan, M., Russell, G., Geneau, R. and Muldoon, L. (2008), ‘Framework for primary care organizations: the importance of a structural domain’, International Journal for Quality in Health Care, 20(5): 308–313.Google Scholar
Hooker, R. and Berlin, L. E. (2002), ‘Trends in the supply of physician assistants and nurse practitioners in the United States’, Health Affairs, 21(5): 174–181.CrossRefGoogle ScholarPubMed
Huang, E. S. and Finegold, K. (2013), ‘Seven million Americans live in areas where demand for primary care may exceed supply by more than 10 percent’, Health Affairs, 32(3): 614–621.Google Scholar
IOM (2010), The Future of Nursing: Leading Change, Advancing Health, Washington, DC: N. A. Press and Institute of Medicine.Google Scholar
Jacobson, P. D., Parker, L. E. and Coulter, I. D. (1998), ‘Nurse practitioners and physician assistants as primary care providers in institutional settings’, Inquiry, 35(4): 432–446.Google ScholarPubMed
Kehrer, B. H. and Intriligator, M. D. (1974), ‘Task delegation in physician office practice’, Inquiry, 11(4): 292–299.Google Scholar
Kirch, D. G., Henderson, M. K. and Dill, M. J. (2012), ‘Physician workforce projections in an era of health care reform’, Annual Review of Medicine, 63: 435–445.Google Scholar
Kleiner, M. M., Marier, A., Won Park, K. and Wing, C. (2014), Relaxing Occupational Licensing Requirements: Analyzing Wages and Prices for a Medical Service’, NBER Working Paper Series Working Paper 19906: 1–54.CrossRefGoogle Scholar
Laurant, M. G., Akkermans, R. P., Sibbald, B. and Grol, R. P. (2008), ‘An overview of patients’ preferences for, and satisfaction with, care provided by general practitioners and nurse practitioners’, Journal of Clinical Nursing, 17(20): 2690–2698.Google Scholar
Lenz, E. R., Mundinger, M. O., Kane, R. L., Hopkins, S. C. and Lin, S. X. (2004), ‘Primary care outcomes in patients treated by nurse practitioners or physicians: two-year follow-up’, Medical Care Research and Review, 61(3): 332–351.Google Scholar
Marsh, G. N. (1991), ‘The future of general practice: caring for larger lists’, British Medical Journal, 303: 1312–1316.Google Scholar
McGuire, T. G. and Pauly, M. V. (1991), ‘Physician response to fee changes with multiple payers’, Journal of Health Economics, 10: 385–410.Google Scholar
Mood, C. (2010), ‘Logistic regression: why we cannot do what we think we can do, and what we can do about it’, European Sociological Review, 26(1): 67–82.Google Scholar
Mundinger, M. O., Kane, R. L., Lenz, E. R., Totten, A. M., Tsai, W.-Y., Cleary, P. D., Friedewald, W. T., Siu, A. L. and Shelanski, M. L. (2000), ‘Primary care outcomes in patients treated by nurse practitioners or physicians’, Journal of the American Medical Association, 238(1): 59–68.CrossRefGoogle Scholar
Naylor, M. D. and Kurtzman, E. T. (2010), ‘The role of nurse practitioners in reinventing primary care’, Health Affairs, 29(5): 893–899.Google Scholar
Newhouse, J. P. (1973), ‘The economics of group practice’, Journal of Human Resources, 8(1): 37–56.Google Scholar
Ohman-Strickland, P. A., Orzano, A. J., Hudson, S. V., Solberg, L. I., DiCiccio-Bloom, B., O’Malley, D., Tallia, A. F., Balasubramanian, B. A. and Crabtree, B. F. (2008), ‘Quality of diabetes care in family medicine practices: influence of nurse-practitioners and physician’s assistants’, Annals of Family Medicine, 6(1): 14–22.Google Scholar
Pohl, J. M., Hanson, C., Newland, J. A. and Cronenwett, L. (2010), ‘Unleashing nurse practitioners’ potential to deliver primary care and lead teams’, Health Affairs, 29(5): 900–905.CrossRefGoogle ScholarPubMed
Reid, R. J., Coleman, K., Johnson, E. A., Fishman, P. A., Hsu, C., Soman, M. P., Trescott, C. E., Erickson, M. and Larson, E. B. (2010), ‘The group health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers’, Health Affairs, 29(5): 835–843.Google Scholar
Reinhardt, U. (1972), ‘A production function for physician services’, Review of Economics and Statistics, 54(1): 55–66.Google Scholar
Rhodes, K. V., Kenney, G. M., Friedman, A. B., Saloner, B., Lawson, C. C., Chearo, D., Wissoker, D. and Polsky, D. (2014), ‘Primary care access for new patients on the eve of health care reform’, JAMA Internal Medicine, 174(6): 861–869.Google Scholar
Richards, A., Carley, J., Jenkins-Clarke, S. and Richards, D. A. (2000), ‘Skill mix between nurses and doctors working in primary care-delegation or allocation: a review of the literature’, International Journal of Nursing Studies, 37: 185–197.Google Scholar
Richards, M. R., Saloner, B., Kenney, G. M., Rhodes, K. V. and Polsky, D. (2014), ‘Access points for the underserved: primary care appointment availability at federally qualified health centers in ten states’, Medical Care, 52(9): 818–825.Google Scholar
Richards, M. R., Saloner, B., Kenney, G. M., Rhodes, K. V. and Polsky, D. (2015), ‘Availability of new Medicaid patient appointments and the role of rural health clinics’, Health Services Research, E-pub ahead of print.Google Scholar
Richardson, G., Maynord, A., Cullum, N. and Kindig, D. (1998), ‘Skill mix changes: substitution or service development?’, Health Policy, 45: 119–132.Google Scholar
Rittenhouse, D. R. and Shortell, S. M. (2009), ‘The patient-centered medical home: will it stand the test of health reform’, Journal of American Medical Association, 301(19): 2038–2040.Google Scholar
Roblin, D., Howard, D. H., Becker, E. R., Adams, E. K. and Roberts, M. H. (2004), ‘Use of midlevel practitioners to achieve labor cost savings in the primary care practice of an MCO’, Health Services Research, 39(3): 607–625.Google Scholar
Rosenthal, T. C. (2008), ‘The medical home: growing evidence to support a new approach to primary care’, Journal of the American Board of Family Medicine, 24(5): 427–440.Google Scholar
Schiff, M. (2012), The Role of Nurse Practitioners in Meeting Increasing Demand for Primary Care’. NGA Paper, National Governors Association, Washington, DC.Google Scholar
Sloan, F. A., Mitchell, J. B. and Cromwell, J. (1978), ‘Physician participation in state Medicaid programs’, Journal of Human Resources, 13(NBER Supplemental): 211–245.Google Scholar
Sommers, B., Gordon, S., Somers, S., Ingram, C. and Epstein, A. (2013), ‘Medicaid on the Eve of Expansion: A Survey of State Medicaid Officials about the ACA’, Health Affairs Blog (Blog Post: December 30).Google Scholar
Spetz, J., Parente, S. T., Town, R. J. and Bazarko, D. (2013), ‘Scope-of-practice laws for nurse practitioners limit cost savings that can be achieved in retail clinics’, Health Affairs, 32(11): 1977–1984.Google Scholar
Stange, K. (2014), ‘How does provider supply and regulation influence health care markets? Evidence from nurse practitioners and physician assistants’, Journal of Health Economics, 33: 1–27.Google Scholar
Steinbrook, R. (2009), ‘Easing the shortage in adult primary care – is it all about money?’, New England Journal of Medicine, 360: 2696–2699.Google Scholar
Stimson, D. H. and Charles, G. (1975), ‘The study of physician extenders in primary care’, Health Services Research, Spring: 6–13.Google Scholar
Thurston, N. K. and Libby, A. M. (2002), ‘A production function for physician services revisited’, Review of Economics and Statistics, 84(1): 184–191.Google Scholar
Whitcomb, M. E. and Cohen, J. J. (2004), ‘The future of primary care medicine’, New England Journal of Medicine, 351(7): 710–712.Google Scholar
Wing, C. and Marier, A. (2014), ‘Effects of occupational regulations on the cost of dental services: evidence from dental insurance claims’, Journal of Health Economics, 34: 131–143.Google Scholar
Wright, W. L., Romboli, J. E., DiTulio, M. A., Wogen, J. and Belletti, D. A. (2011), ‘Hypertension treatment and control within an independent nurse practitioner setting’, American Journal of Managed Care, 17(1): 58–65.Google ScholarPubMed
Zeckhauser, R. and Eliastam, M. (1974), ‘The productivity potential of the physician assistant’, Journal of Human Resources, 9(1): 95–116.Google Scholar