Characteristics of Primary Care Physicians in Patient-centered Medical Home Practices: United States, 2013.

Objective-This report describes the characteristics of primary care physicians in patient-centered medical home (PCMH) practices and compares these characteristics with those of primary care physicians in non-PCMH practices. Methods-The data presented in this report were collected during the induction interview for the 2013 National Ambulatory Medical Care Survey, a national probability sample survey of nonfederal physicians who see patients in office settings in the United States. Analyses exclude anesthesiologists, radiologists, pathologists, and physicians in community health centers. In this report, PCMH status is self-defined as having been certified by one of the following organizations: Accreditation Association for Ambulatory Health Care, The Joint Commission, National Committee for Quality Assurance, URAC, or other certifying bodies. Estimates exclude physicians missing information on PCMH status. Sample data are weighted to produce national estimates of physicians and characteristics of their practices. Results-In 2013, 18.0% of office-based primary care physicians worked in practices certified as PCMHs. A higher percentage of primary care physicians in PCMH practices (68.8%) had at least one physician assistant, nurse practitioner, or certified nurse midwife on staff compared with non-PCMH practices (47.7%). A higher percentage of primary care physicians in PCMH practices reported electronic transmission (69.6%) as the primary method for receiving information on patients hospitalized or seen in emergency departments compared with non-PCMH practices (41.5%). The percentage of primary care physicians in practices reporting quality measures or quality indicators to payers or organizations monitoring health care quality was higher in PCMH practices (86.8%) compared with non-PCMH practices (70.2%).

Emergency Department Use in the Country's Five Most Populous States and the Total United States, 2012.

KEY FINDINGS: Data from the National Hospital Ambulatory Medical Care Survey, 2012 •In 2012, the emergency department (ED) visit rate in the United States was 42 visits per 100 persons. •The ED visit rate among the five most populous states ranged from 37 visits per 100 persons in New York to 49 visits per 100 persons in Texas. •The percentage of ED visits resulting in admission to the same hospital was higher in California (16%) and Florida (17%) than was observed nationally (11%). •The percentage of visits to EDs located in metropolitan statistical areas was higher in California (98%), Florida (97%), and New York (92%) than was observed nationally (85%).

Expected Source of Payment at Emergency Department Visits for Adults Aged 18-64 for the United States and in the Five Most Populous States, 2012.

KEY FINDINGS: Data from the National Hospital Ambulatory Medical Care Survey, 2012 •In 2012, 33% of emergency department (ED) visits in the United States made by adults aged 18-64 had private insurance as the expected source of payment. This percentage was lower for Illinois than for the total United States. •In 2012, 21% of ED visits made by adults aged 18-64 had Medicaid as the expected source of payment. This percentage varied across the five most populous states, ranging from 12% in Texas to 30% in New York. •In 2012, 20% of ED visits in the United States were made by adults aged 18-64 with no insurance (self-pay, no charge, charity, or a combination of these types were the only reported expected sources of payment).This percentage varied across the five most populous states, ranging from 15% in New York to 28% in Texas.

Nonresponse Bias in Estimates From the 2012 National Ambulatory Medical Care Survey.

BACKGROUND: The National Ambulatory Medical Care Survey (NAMCS) is an annual, nationally representative sample survey of physicians and of visits to physicians. Two major changes were made to the 2012 NAMCS to support reliable state estimates. The sampling design changed from an area sample to a fivefold-larger list sample of physicians stratified by the nine U.S. Census Bureau divisions and 34 states. At the same time, the data collection mode changed from paper forms to laptop-assisted data collection and from physician or office staff abstraction of medical records to predominantly Census interviewer abstraction using automated Patient Record Forms (PRFs). OBJECTIVES: This report presents an analysis of potential nonresponse bias in 2012 NAMCS estimates of physicians and visits to physicians. This analysis used two sets of physician-based estimates: one measuring the completion of the physician induction interview and another based on completing any PRF. Evaluation of visit response was measured by the percentage of expected PRFs completed. For each type of physician estimate, response was evaluated by (a) comparing percent distributions of respondents and nonrespondents by physician characteristics available for all in-scope sample physicians, (b) comparing response rates by physician characteristics with the national response rate, and (c) analyzing nonresponse bias after adjustments for nonresponse were applied in survey weights. For visit estimates, response was evaluated by (a) comparing the percent distributions of expected visits and completed visits, (b) comparing visit response rates by physician characteristics with the national visit response rate, and (c) analyzing visit-level nonresponse bias after adjustments for nonresponse were applied in visit survey weights. Finally, potential bias in the two physician-level estimates was computed by comparing them with those from an external survey.

Toward a More Complete Picture of Outpatient, Office-Based Health Care in the U.S.

The healthcare system in the U.S., particularly outpatient, office-based care, has been shifting toward service delivery by advanced practice providers, particularly nurse practitioners (NPs) and physician assistants (PAs). The National Ambulatory Medical Care Survey (NAMCS), conducted by the National Center for Health Statistics (NCHS) at the Centers for Disease Control and Prevention, is the leading source of nationally representative data on care delivered by office-based physicians. This paper first describes NAMCS, then discusses key NAMCS expansion efforts, and finally presents major findings from two exploratory studies that assess the feasibility of collecting data from NPs and PAs as sampled providers in NAMCS. The first NAMCS expansion effort began in 2006 when the NAMCS sample was expanded to include community health centers and started collecting and disseminating data on physicians, NPs, PAs, and nurse midwives in these settings. Then, in 2013, NCHS included workforce questions in NAMCS on the composition and clinical tasks of all healthcare staff in physician offices. Finally, in 2013-2014, NCHS conducted two exploratory studies and found that collecting data from NPs and PAs as sampled providers in NAMCS is feasible. However, modifications to the current NAMCS procedures may be necessary, for example, changing recruitment strategies, visit sampling procedures, and physician-centric survey items. Collectively, these NCHS initiatives are important for healthcare research, practice, and policy communities in their efforts toward providing a more complete picture of the changing outpatient, office-based workforce, team-based care approach, and service utilization in the U.S.

State Variation in Preventive Care Visits, by Patient Characteristics, 2012.

KEY FINDINGS: Data from the National Ambulatory Medical Care Survey, 2012. In 2012, 61.4 preventive care visits were made to office-based physicians per 100 persons. The female rate (76.6 visits per 100 females) exceeded the male rate (45.4 visits per 100 males) by 69%. Among the 34 most populous states, the rate of preventive care visits exceeded the national rate in 1 state (Connecticut) and was lower than the national rate in 11 states (Arkansas, Indiana, Iowa, Michigan, Missouri, North Carolina, Oklahoma, Oregon, Pennsylvania, South Carolina, and Washington). The rate of preventive care visits to primary care physicians in the 34 most populous states exceeded the national rate in 1 state (Connecticut) and was lower than the national rate in 7 states (Arkansas, Indiana, Iowa, Missouri, North Carolina, Pennsylvania, and Washington).

Adoption of Certified Electronic Health Record Systems and Electronic Information Sharing in Physician Offices: United States, 2013 and 2014.

KEY FINDINGS: Data from the 2014 National Electronic Health Records Survey. In 2014, 74.1% of office-based physicians had a certified electronic health record (EHR) system, up from 67.5% in 2013. The percentage of physicians who had a certified EHR system ranged from 58.8% in Alaska to 88.6% in Minnesota. In 2014, 32.5% of office-based physicians with a certified EHR system were electronically sharing patient health information with external providers. The percentage of physicians with a certified EHR system electronically sharing patient health information with external providers ranged from 17.7% in New Jersey to 58.8% in North Dakota.

Variation in Physician Office Visit Rates by Patient Characteristics and State, 2012.

In 2012, 74% of children and adults with a usual place to visit listed a doctor's office as their usual place for care (1,2). This report examines the rate of physician office visits by patient age, sex, and state. Visits by adults with private insurance as their expected source of payment were also examined. Estimates are based on the 2012 National Ambulatory Medical Care Survey (NAMCS), a nationally representative survey of physician office visits. State estimates for the 34 most populous states are available for the first time. State refers to the location of the physician office visit.

In which states are physician assistants or nurse practitioners more likely to work in primary care?

OBJECTIVE: Examine availability of physician assistants (PAs) or nurse practitioners (NPs) in primary care physician practices by state and by state PA and NP scope-of-practice laws. METHODS: Availability of PAs and NPs in primary care practices was examined in multivariate analysis using a 2012 state-based, nationally representative survey of office-based physicians. Covariates included practice characteristics, state, and in a separate model, PA and NP scope-of-practice variables. RESULTS: After controlling for practice characteristics, higher use of PAs and NPs was found in three states (Minnesota, Montana, and South Dakota). In a separate model, higher use of PAs or NPs was associated with favorable PA scope-of-practice laws, but not with NP scope-of-practice laws. CONCLUSIONS: Higher availability of PAs or NPs was associated with favorable PA scope-of-practice laws. Lack of association between PA or NP availability and NP scope-of-practice laws requires further investigation.

Nurse practitioners, physician assistants, and physicians in community health centers, 2006-2010.

PURPOSE: Community health centers (CHCs) fill a vital role in providing health care to underserved populations. This project compares characteristics of patient visits to nurse practitioners (NPs), physician assistants (PAs), and physicians in CHCs. METHODS: This study analyzes 2006-2010 annual survey data from the National Ambulatory Medical Care Survey CHC sample, a representative national sample of CHC providers and patient visits. We examine trends in provider mix in CHCs and compare NPs, PAs, and physicians with regard to patient and visit attributes. Survey weights are used to produce national estimates. RESULTS: There were, on average, 36,469,000 patient visits per year to 150,100 providers at CHCs; 69% of visits were to physicians, 21% were to NPs, and 10% were to PAs. Compared to visits to NPs, visits made to physicians and PAs tended to be for chronic disease treatment and for patients whom they serve as primary care providers. Visits to NPs tended to be for preventive care. CONCLUSIONS: This study found more similarities than differences in characteristics of patients and patient visits to physicians, NPs, and PAs in CHCs. When statistical differences were observed, NP patient and visit characteristics tended to be different from those of physicians. IMPLICATIONS: Results provide detailed information about visits to NPs and PAs in a setting where they constitute a significant portion of providers and care for vulnerable populations. Results can inform future workforce approaches.

Acceptance of new patients with public and private insurance by office-based physicians: United States, 2013.

Physician acceptance of new Medicaid patients has shown to be lower than acceptance of new Medicare patients or new privately insured patients. Acceptance of new Medicaid patients also has shown to be lower in states with lower Medicaid payment rates to physicians. Using the 2013 National Electronic Health Records Survey (NEHRS), this report summarizes physician acceptance of new patients with Medicaid, Medicare, and private insurance. It also summarizes information on how these acceptance rates vary by select physician characteristics and by state.

Progress with electronic health record adoption among emergency and outpatient departments: United States, 2006-2011.

The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 provides incentive payments to eligible hospitals and providers that demonstrate the meaningful use of a certified electronic health record (EHR) system . This report describes the adoption of EHRs in hospital emergency departments (EDs) and outpatient departments (OPDs) from 2006 through 2011 using the National Hospital Ambulatory Medical Care Survey (NHAMCS).

The role of health information technology in care coordination in the United States.

OBJECTIVES: Examine the extent to which office-based physicians in the United States receive patient health information necessary to coordinate care across settings and determine whether receipt of information needed to coordinate care is associated with use of health information technology (HIT) (defined by presence or absence of electronic health record system and electronic sharing of information). RESEARCH DESIGN: Cross-sectional study using the 2012 National Electronic Health Records Survey (65% weighted response rate). SUBJECTS: Office-based physicians. MEASURES: Use of HIT and 3 types of patient health information needed to coordinate care. RESULTS: In 2012, 64% of physicians routinely received the results of a patient's consultation with a provider outside of their practice, whereas 46% routinely received a patient's history and reason for a referred consultation from a provider outside of their practice. About 54% of physicians reported routinely receiving a patient's hospital discharge information. In adjusted analysis, significant differences in receiving necessary information were observed by use of HIT. Compared with those not using HIT, a lower percentage of physicians who used an electronic health record system and shared patient health information electronically failed to receive the results of outside consultations or patient's history and reason for a referred consultation. No significant differences were observed for the receipt of hospital discharge information by use of HIT. Among physicians routinely receiving information needed for care coordination, at least 54% of them did not receive the information electronically. CONCLUSIONS: Although a higher percentage of physicians using HIT received patient information necessary for care coordination than those who did not use HIT, more than one third did not routinely receive the needed patient information at all.

State variability in supply of office-based primary care providers: United States, 2012.

KEY FINDINGS: Data from the National Ambulatory Medical Care Survey (NAMCS) and the NAMCS Electronic Health Records Survey In 2012, 46.1 primary care physicians and 65.5 specialists were available per 100,000 population. From 2002 through 2012, the supply of specialists consistently exceeded the supply of primary care physicians. Compared with the national average, the supply of primary care physicians was higher in Massachusetts, Rhode Island, Vermont, and Washington; it was lower in Arkansas, Georgia, Mississippi, Nevada, New Mexico, and Texas. In 2012, 53.0% of office-based primary care physicians worked with physician assistants or nurse practitioners. Compared with the national average, the percentage of physicians working with physician assistants or nurse practitioners was higher in 19 states and lower in Georgia. Primary care providers include primary care physicians, physician assistants, and nurse practitioners. Primary care physicians are those in family and general practice, internal medicine, geriatrics, and pediatrics (1). Physician assistants are state-licensed health professionals practicing medicine under a physician's supervision. Nurse practitioners are registered nurses (RNs) with advanced clinical training (2-6). The ability to obtain primary care depends on the availability of primary care providers (3). This report presents state estimates of the supply of primary care physicians per capita, as well as the availability of physician assistants or nurse practitioners in primary care physicians' practices. Estimates are based on data from the National Ambulatory Medical Care Survey (NAMCS), Electronic Health Records (EHR) Survey, a nationally representative survey of office-based physicians.

Trends in electronic health record system use among office-based physicians: United States, 2007-2012.

OBJECTIVES: This report presents trends in the adoption of electronic health records (EHRs) by office-based physicians during 2007-2012. Rates of adoption are compared by selected physician and practice characteristics. METHODS: The National Ambulatory Medical Care Survey (NAMCS) is based on a national probability sample of nonfederal office-based physicians who see patients in an office setting. Prior to 2008, data on physician characteristics were collected through in-person interviews with physicians. To increase the sample for analyzing physician adoption of EHR systems, starting in 2008, NAMCS physician interview data were supplemented with data from an EHR mail survey. This report presents estimates from the 2007 in-person interviews, combined 2008-2010 data from both the in-person interviews and the EHR mail surveys, and 2011-2012 data from the EHR mail surveys. Sample data were weighted to produce national estimates of office-based physician characteristics and their practices. RESULTS: In 2012, 71.8% of office-based physicians reported using any type of EHR system, up from 34.8% in 2007. In 2012, 39.6% of physicians had an EHR system with features meeting the criteria of a basic system, up from 11.8% in 2007; 23.5% of office-based physicians had an EHR system with features meeting the criteria of a fully functional system in 2012, up from 3.8% in 2007. In 2007, a wide gap existed in use of any type of EHR system between physicians in practices with 11 or more physicians (74.3%) compared with physicians in smaller practices (20.6% among solo practitioners); the gap, however, narrowed during 2007-2012. In 2007, no significant gap was observed in adoption of a fully functional system between primary care (4.7%) and nonprimary care physicians (2.8%); the gap, however, widened over time (27.9% compared with 19.4% in 2012). The difference in adoption of a fully functional system between physicians in practices with 11 or more physicians compared with solo practitioners was 10.4 percentage points in 2007; the gap widened to 30.6 percentage points in 2012.

Use and characteristics of electronic health record systems among office-based physician practices: United States, 2001-2013.

KEY FINDINGS: In 2013, 78% of office-based physicians used any type of electronic health record (EHR) system, up from 18% in 2001. In 2013, 48% of office-based physicians reported having a system that met the criteria for a basic system, up from 11% in 2006. The percentage of physicians with basic systems by state ranged from 21% in New Jersey to 83% in North Dakota. In 2013, 69% of office-based physicians reported that they intended to participate (i.e., they planned to apply or already had applied) in "meaningful use" incentives. About 13% of all office-based physicians reported that they both intended to participate in meaningful use incentives and had EHR systems with the capabilities to support 14 of the Stage 2 Core Set objectives for meaningful use. From 2010 (the earliest year that trend data are available) to 2013, physician adoption of EHRs able to support various Stage 2 meaningful use objectives increased significantly. The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 authorized incentive payments to increase physician adoption of electronic health record (EHR) systems (1,2). The Medicare and Medicaid EHR Incentive Programs are staged in three steps, with increasing requirements for participation. To receive an EHR incentive payment, physicians must show that they are "meaningfully using" certified EHRs by meeting certain objectives (3,4). This report describes trends in the adoption of EHR systems from 2001 through 2013, as well as physicians' intent to participate in the EHR Incentive Programs and their readiness to meet 14 of the Stage 2 Core Set objectives for meaningful use in 2013.

Time spent with patients by physicians, nurse practitioners, and physician assistants in community health centers, 2006-2010.

BACKGROUND: As health systems struggle to meet access, cost and quality goals in the setting of increased demand, nurse practitioners (NPs) and physician assistants (PAs) are expected to help meet the need for care. The amount of time spent with each patient can affect the clinical productivity, quality of care, and satisfaction of patients and clinicians. This paper compares time spent per patient in community health centers by whether the provider is a physician, NP, or PA. METHODS: This paper uses National Ambulatory Medical Care Survey (NAMCS) Community Health Center (CHC) data from 2006-2010. The NAMCS CHC strata is a national sample of CHCs, providers within CHCs, and patient visits to CHCs. Provider characteristics and variables related to time spent with patients across provider types were compared using t tests and chi square tests of association. Multivariate linear regression analysis was used to compare time spent with patients, controlling for patient and visit characteristics. RESULTS: There were no differences in the number of visits by provider type, but PAs saw patients for a slightly larger portion of the week (3.8 days) than did physicians (3.5 days, p<0.05) or NPs (3.4 days, p<0.05). There were no statistical differences in the mean time spent per patient in the crude and adjusted analyses. CONCLUSIONS: Time spent per patient in CHCs is similar for physicians, NPs and PAs. This information may be useful to planners concerned with health system capacity and cost efficiency, and has implications for patient and provider satisfaction.

Emergency department visits and resulting hospitalizations by elderly nursing home residents, 2001-2008.

This study examines emergency department (ED) visits by nursing home (NH) residents aged 65 and over, and factors associated with hospital admission from the ED visit using data from the 2001-2008 National Hospital Ambulatory Medical Care Survey. Cross-sectional analyses were conducted on patient characteristics, diagnosis, procedures received, and triage status. On average, elderly NH residents visited EDs at a rate of 123 visits per 100 institutionalized persons. Nearly 15% of all ED visits had ambulatory care sensitive condition diagnoses. Nearly half of these visits resulted in hospital admission; chronic obstructive pulmonary disease, congestive heart failure, kidney/urinary tract infection, and dehydration were associated with higher odds of admission. Previous studies suggested that adequate medical staffing and appropriate care in the NH could reduce ED visits and hospital admissions. Recent initiatives seek to reduce ED visits and hospitalizations by providing financial incentives to spur better coordination between NH and hospital.

Wait time for treatment in hospital emergency departments: 2009.

From 1999 through 2009, the number of visits to emergency departments (EDs) increased 32%, from 102.8 million visits in 1999 to 136.1 million visits in 2009 (1,2). In some hospitals, increased ED visit volume has resulted in ED crowding and increased wait times for minor and sometimes serious problems, such as myocardial infarction (3­7). This report describes the recent trend in wait times for treatment in EDs, and focuses on how wait times for treatment varied by two ED crowding measures: ambulance diversions and boarding of admitted patients.