Primary Health Care in Community Health Centers and Comparison with Office-based Practice

Esther Hing; Roderick S. Hooker; Jill J. Ashman


J Community Health. 2011;36(3):406-413. 

In This Article

Abstract and Introduction


We examine the roles of nurse practitioners (NPs), physician assistants (PAs), and nurse midwives (CNMs) in community health centers (CHCs). We also compare primary care physicians in CHCs with office-based physicians. Estimates are from the National Ambulatory Medical Care Survey, a nationally representative annual survey of nonfederal, office-based patient care physicians and their visits. Analysis of primary care delivery in CHCs and office-based practices are based on 1,434 providers and their visits (n = 32,300). During 2006–2007, on average, physicians comprised 70% of CHC clinicians, with NPs (20%), PAs (9%), and CNMs (1%) making up the remainder. PAs, NPs, and CNMs provided care in almost a third of CHC primary care visits; 87% of visits to these CHC providers were independent of physicians. Types of patients seen by clinicians suggest a division of labor in caring for CHC patients. NPs and PAs were more likely than physicians to report providing health education services. There were no other differences among services examined. Office-based physicians were less likely to work alongside PAs/NPs/CNMs than CHC physicians. CHC staffing is contingent on a variety of providers. CHC staffing patterns may serve as models of primary care staffing for office practices as demand for primary care services nationwide increases.


In the US, non-physician clinicians (physician assistants (PAs), nurse practitioners (NPs) and nurse midwives (CNMs)) are underutilized in primary care practices. The reasons for this vary; from higher pay in subspecialty areas to lifestyle preferences.[1] Although PAs were introduced to bolster the primary care workforce, options have grown in both surgical and medical specialties.[2] In addition, primary care practices often cannot afford to provide non-physician clinician services since the current visit-based payment system provides disincentives to their use,[3,4] while state regulations regarding both the scope of practice and prescribing authority for NPs hinder utilizing NPs to their full potential.[5] Finally, physician training and culture has not emphasized working as part of a team; most physicians are trained to work autonomously.[6,7]

Community health centers (CHCs) are an exception in primary care. For 40 years, CHCs have delivered primary care to the uninsured, the homeless, migrant workers, and other medically underserved populations.[8] To receive Section 330 grant funds through the Public Health Service Act, CHCs, (also known as federally qualified health centers [FQHCs]), must provide comprehensive primary health care services as well as ancillary services that facilitate access to health care including case-management, translation and transportation services. This wide array of CHC services has fostered a team-based approach to managing health care among physicians, non-physician clinicians and other CHC staff.[9,10] Examination of CHC utilization patterns may help delineate the roles served by these clinicians.

We examined care provided by primary care providers [physicians, nurse practitioners (NPs) and physician assistants (PAs)] among federally funded and look-alike CHCs. We also compared physician and visit characteristics of primary care physicians in CHCs and office-based practices. In this paper, primary care physicians include those in general and family practice, internal medicine, pediatrics, and obstetrics/gynecology. Patterns of care were examined using data from 2006 and 2007 National Ambulatory Medical Care Survey (NAMCS), a nationally representative survey of visits to non-federal office-based physicians. Reliable CHC clinician and visit estimates are made possible by the inclusion of a separate stratum of CHCs in NAMCS beginning in 2006.


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