While primary care physician office visits fell from 2012 to 2016, office visits to nurse practitioners and physician assistants rose.
Primary care practices have been on the frontlines of changes sweeping across the healthcare industry, including the advancement of patient-centered medical homes, consolidation, and integration of primary care and behavioral health.
The decline in primary care physician (PCP) office visits was partially offset by a 129% increase in office visits with nurse practitioners (NPs) and physician assistants (PAs) from 2012 to 2016.
The recent decrease in office visits to primary care physicians (PCPs) and increase in NP and PA visits is likely linked to three primary factors, Amanda Frost, PhD, senior researcher at HCCI and lead author of this week's report, told HealthLeaders.
- First, there has been an expansion in scope of practice laws for NPs and PAs, Frost says. "Scope of practice laws are largely defined by individual states and have changed quite a bit over the last decade. These laws cover things such as whether non-physicians are allowed to prescribe prescriptions, what type of care they can provide, and whether they can practice independently or require physician oversight."
- Second, health plan changes are impacting patients' choice of providers, Frost says. "Benefit design features can influence the choices that patients make about where to seek care. For example, under an HMO model, primary care is emphasized, and patients are often required to seek referrals from their PCP prior to seeing specialists. In contrast, Preferred Provider Organization and Point of Service arrangements often do not require PCP referrals for specialist care."
- Third, physician shortages are driving patients to seek alternatives to PCP caregivers, she says. "Patients may increasingly see nurse practitioners and physician assistants as a substitute for primary care physicians, especially in areas with PCP shortages where scheduling an office visit to a PCP is more difficult."
Key data points
To the extent that patients are shifting away from PCP office visits to see NPs and PAs, the cost savings is minimal, according to the HCCI report, which is based on employer-sponsored insurance data.
In 2016, the average cost of an office visit to a PCP was $106, and the average cost of an office visit to an NP or a PA was $103, the report says.
The report has several other primary findings:
- Across all types of providers, there was a 2% overall drop in total office visits
- In 2012, 51% of office visits for patients under age 65 were to PCPs and that figure dropped to 43% in 2016
- The rise in visits to NPs and PAs accounted for only 42% of the drop in PCP visits
- On a state-by-state basis, the decrease in PCP office visits ranged from 6% in Washington, D.C., to 31% in North Dakota
- On a state-by-state basis, increases in NP and PA office visits ranged from 37% in New Mexico to 285% in Massachusetts
Whether it is delivered by PCPs or NPs and PAs, primary care offers a high level of value for patients, the report says.
"Access to PCPs helps keep healthcare costs low, as spending is lower on PCPs than specialists or emergency care. Primary care also helps keep people healthier and out of emergency rooms," the report says.
The role of NPs and PAs in primary care is evolving, the report says.
"Having more NPs and PAs provide primary care may ease potential shortages in PCPs and allow PCPs to focus on more clinically complex primary care. However, the laws governing scope of practice for these non-physician providers vary widely by state. In some states, NPs and PAs have full practice authority, while in others they are restricted from independent practice and require the oversight and billing of a physician."
Christopher Cheney is the senior clinical care editor at HealthLeaders.
The decline in office visits to primary care physicians was only partially offset by a large rise in office visits to nurse practitioners and physician assistants.
An expansion in scope of practice laws for nurse practitioners and physician assistants is one of the likely drivers for decreased primary care physician visits.
For all provider types, there was a 2% decrease in office visits.